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ABSTRACTS
Year : 2018  |  Volume : 12  |  Issue : 4  |  Page : 254-304

Abstracts


Date of Web Publication18-Dec-2018

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How to cite this article:
. Abstracts. Indian J Transplant 2018;12:254-304

How to cite this URL:
. Abstracts. Indian J Transplant [serial online] 2018 [cited 2019 Mar 23];12:254-304. Available from: http://www.ijtonline.in/text.asp?2018/12/4/254/247816




  Efficacy of Different Doses of Rituximab in Desensitization for ABO-Incompatible Kidney Transplantation Top


Nikhil Shinde, D. S. Ray, Pratik Das, Kaustuv Mukherjee, Nidhi Agrawal

RTIICS, Kolkata, West Bengal, India. E-mail: docnidhi21@yahoo.com

Background: The goal of transplantation is to achieve good graft function with minimal immunosuppression. Rituximab is used for desensitization in ABO-incompatible (ABOi) kidney transplant at variable doses ranging from 100 to 500 mg/body. The optimal dose of rituximab which balances good graft function with least side effects is not known. Aims of Study: To study the effect of two different doses of rituximab on B-cell count, graft function, and adverse events in ABOi renal transplantation. Methods: Study Design: This was a prospective, randomized trial conducted between December 2016 and November 2017. Inclusion Criteria: (1) Prospective ABOi kidney-transplant recipients with baseline antibody titer < 1:512 and (2) age >18 years. Exclusion Criteria: (1) Re-transplant, (2) hepatitis B and C, and HIV positivity, (3) ABOi kidney-transplant recipients with antibody titer of >1:512, (4) those who did not give written informed consent. Methodology: Prospective recipients received rituximab (Group A = 100 mg, Group B = 200 mg) 14 days before the date of transplantation. Plasmapheresis was given as per requirement to target antibody titer of <1:32. Each plasmapheresis was followed by 5 g of intravenous immunoglobulin. Oral immunosuppressants comprising tacrolimus (0.15 mg/kg/d), MMF (360 mg TDS), and prednisolone (20 mg/d) were started 14 days before transplant. All patients received ATG induction. Follow-up: 6 months posttransplant. Outcome Measures: B-cell count, graft loss, rejection episodes, infections, and patient survival. Results: A total of 52 patients were included, 26 in each arm. Number of plasmapheresis required to achieve antibody titer of <1:32 were 4.12 ± 2.25 and 5.73 ± 2.3 in Group A and Group B, respectively (P = 0.078). Absolute CD20 count was similar between the groups at day 1, 1 month, 3 months, and 6 months posttransplant. There was no significant difference in serum creatinine at 1 and 3 months. At 6-month posttransplant, serum creatinine was higher in Group B (1.69 ± 0.81 vs. 1.24 ± 0.28, P = 0.025). There was no significant difference in proportion of patients with rejection between the two groups. There was no graft loss in either group. There was one death in each group, both with functioning graft. Proportion of patients with infections were significantly higher in Group B (15.4% vs. 3.9%, P = 0.035). Conclusion: ABOi renal transplant with low-dose rituximab before transplant along with plasmapheresis and triple immunosuppressants has good outcome in terms of patient and graft survival and low incidence of infection.


  Disseminated Cryptococcosis Top


Manpreet Kaur Jhingar, Vikas Makkardr Ravi Angral, P. M. Sohal, Simran Kaur Chahal, Suman Sethi

Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail: dr.manpreetjhingar@gmail.com

Background: A 36-year-old male presented with renal allograft recipient admitted with cutaneous lesions. Aims of Study: The study was aimed to look at skin variants in renal allograft recipients. Methods: He underwent skin and cervical lymph node biopsy. Results: Both biopsies were suggestive of cryptococcosis. Conclusion: He started on amphotericin B and flucytosine.


  Influence of CYP3A5*3 Genetic Polymorphism on Dose-Adjusted Trough Levels of Tacrolimus in South Indian Renal-Transplant Patients Top


Nabadwip Pathak, P. Laxmi, D. G. Shewade, S. Parameswaran

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E-mail: sparameswaran@outlook.com

Background: Tacrolimus (Tac) is the most common immunosuppressant used in renal-transplant patients. The problem with Tac is the difficulty in maintaining therapeutic drug concentration, resulting in therapeutic failure or toxicity. CYP3A5*3 single nucleotide polymorphism is one among the many factors, which affects Tac trough levels. The presence of the mutant gene can result in increased drug level and thereby result in toxicities. Aims of Study: To compare the dose-adjusted trough levels of Tac among CYP3A5*3 genotypes. Methods: The study was conducted in 100 renal-transplant patients who attended the Nephrology Outpatient Department in Jawaharlal Institute of Postgraduate Medical Education and Research and on Tac after at least 3 months of transplantation. Steady-state Tac trough levels were measured using LCMS/MS and genotyping for CYP3A5 was done by real-time polymerase chain reaction. Results: Patients inheriting CYP3A5*3/*3 variant or the nonexpressors had an increased dose-adjusted Tac level (2.2 ng/ml/mg) when compared to patients inheriting CYP3A5*1/*1 and CYP3A5*1/*3 (1.1 and 1.3 ng/ml/mg, P = 0.004) which are the expressors. Conclusion: There is significant influence of CYP3A5*3 genetic polymorphism (6986A>G) on dose-adjusted trough levels of Tac in renal-transplant patients in South Indian population. Genetic testing before transplant may reduce need for drug level monitoring.


  Kidney Allocation Based upon Virtual Cross-Match in Deceased Donor Program Top


Abhinav Seth, Ashish Sharma, Sarbpreet Singh, Deepesh Benjamine Kenwar, Krishan Lal Gupta, Gaurav Shankar Pandey, Vidyasagar Kallepalli

Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drabhinavseth@gmail.com

Background: Allocation of the kidney in deceased donor is based on waiting list in our country and final acceptance is on crossmatch result. In this context, patients with high titer of antibodies are not able to get the offer for transplant and transplanting these patient leads to poorer outcome. The Luminex Single-Antigen Bead assay allows detection of antibodies in the recipient against the donor antigens, and having this information at the time of organ allocation can improve short- and long-term outcomes. Aims of Study: To discuss the role of virtual crossmatches for allocating kidney from deceased donor. Methods: All sensitized recipients listed for deceased donor renal transplant were screened by Luminex technology for the presence of antibodies (n = 63). Pretransplant HLA genotyping for A, B, and DRB1 loci was performed using Luminex and sequence-specific primers methods at the time of donor identification. Only those patients where virtual cross-match was negative were called for complement-dependent cytotoxicity cross-match before organ allocation. This method was used to transplant kidneys from a deceased donor in eight recipients who were sensitized (history of blood transfusion, previous transplant, multiple pregnancies, or previous cross-match positive and with antibody mean fluorescence intensity [MFI] or >5000 on Luminex). These patients had pretransplant antibodies against the HLA with MFI in the range of 1211–21,444 on Luminex single antigen. These patients were transplanted only if they had a donor-specific antibody MFI <1000 and a negative complement-dependent cytotoxicity cross-match was negative. Results: The mean age of recipients and donor was 39.38 ± 9.43 and 38.13 ± 8.31 years, respectively. There were six female recipients. The cause of end-stage renal disease was diabetic nephropathy in two patients, one patient each suffered from nephrotic syndrome, IgA nephropathy, membranoproliferative glomerulonephritis type I, while it was unknown in three patients. The mean cold ischemia time was 473.86 min. None of these patients had hyperacute rejection or suffered from infection. The average follow-up was 2.1 ± 1.89 months (median = 1 month). The patient mean creatinine at discharge was 1.27 ± 0.24 mg/dl and at 1 month was 1.13 ± 0.3 mg/dl. Biopsy-proven acute rejection was seen in one patient. Conclusion: Kidney allocation for sensitized patients from deceased donor based on virtual crossmatch may help in achieving better outcome in terms of improved graft function and preventing hyperacute rejection.


  Adequacy and Safety of Transplant Renal Biopsy with 18G versus 20G Biopsy Needle Top


Pawan Deore, Zaheer Virani, Hepal Vora, Hitesh Gulhane, Ishan Parekh, Menal Wali, Prashant Rajput, Bharat Shah

Institute of Renal Sciences, Global Hospital, Mumbai, Maharashtra, India. E-mail: drpawankem@gmail.com

Background: Transplant renal biopsies (TRBs) are performed for the evaluation of allograft dysfunction. Procedure is done with real-time ultrasound guidance, yet that does not guarantee total safety. Bigger core needle gives a good tissue yield with some risk of complication. Smaller core needle may ensure lesser complications, but do they give a good tissue yield. Aims of Study: To compare the tissue yield and complication rates between TRBs done by 18G versus 20G biopsy gun. Methods: A retrospective observational study was done which included all patients who underwent TRBs between August 1, 2015, and July 31, 2018, at a tertiary hospital. All TRBs were done either using 18G or 20G biopsy needle depending on the patient profile. Adequacy of tissue was judged by a number of glomeruli obtained (≤5). Major complications which required intervention were documented. Results: A total of 200 TRBs were done during the study period. Among them, 172 were done using 18G automatic gun and 28 were done with 20G semiautomatic biopsy needle. Mean number of glomeruli obtained using 18G was 8.1 ± 3.5; however, yield was significantly less with 20G (mean number of glomeruli 5.2 ± 2.4 (P = 0.008). Gross hematuria was seen in less number of patients with 20G needle (3.5% vs. 6.4%). Major complication rates which required intervention were seen in only four patients; all these were done using 18G biopsy guns. There were no complications with 20G; however, two patients required re-biopsy due to inadequate sample. Diagnostic accuracy was similar with 18G as well as 20G. Conclusion: While no major complications occurred with 20G, two patients had to undergo re-biopsy due to inadequate sample. Thus, using 20G needle may have lesser complication rates, but the tissue yield is poor. There is no major advantage of using 20G needle over 18G.


  Ischemic Stroke in a Renal-Transplant Recipient: A Rare Cause: Cryptococcal Meningoencephalitis Top


Vivek Sood, K. L. Gupta, H. S. Kohli, Manish Rathi, Vivek Kumar, Raja Ramachandran, Jasmine Sethi

PGIMER, Chandigarh, India. E-mail: viverit@gmail.com

Background: Cryptococcal infection comprises 2.8% of opportunistic infections in renal-transplant recipients (RTRs). Most common organ affected is central nervous system (CNS) and usual presentation is with meningoencephalitis. Ischemic stroke consequent to cryptococcal meningoencephalitis is rare and possibly due to strangulation of vessels by exudates causing vasculitis with thrombosis. We report an unusual case of cryptococcal meningoencephalitis presenting as ischemic stroke in RTR and successfully recovering following appropriate antifungal treatment. Aims of Study: To report an unusual case of incidental cryptococcemia in an RTR progressing to ischemic stroke secondary to cryptococcal meningoencephalitis with successful recovery following antifungal treatment. Methods: A 55-year-old male presented with left hemiparesis for 1 day with no history of fever, headache, vomiting, seizures, syncope, ear discharge, or trauma. He had undergone LERRAT 2 years back with baseline creatinine of 1.4 mg/dl. One month back, he received pulse steroid for acute cellular rejection. A week later, his blood culture grew Cryptococcus. Although cryptococcemia was incidental and asymptomatic, he was initiated on amphotericin. A week later, he developed acute onset, progressive left hemiparesis for 1 day. He had left UMN hemiparesis, neck stiffness, and left plantar extensor. His creatinine was 2.5 mg/dL with bland urine. Magnetic resonance imaging was suggestive of multiple lacunar infarcts around circle of Willis. Cerebrospinal fluid (CSF) India ink showed encapsulated yeast and Sabouraud agar grew Cryptococcus. Flucytosine 100 mg/kg/day was added followed by CSF examination every 2 weeks till sterile. The patient had near-complete recovery and received consolidation phase with fluconazole (6 mg/kg/day × 8weeks) and maintenance phase (3 mg/kg/day for 12 months). Results: Stroke is a life-threatening complication in RTRs with ischemic stroke contributing to over 65%. The risk increases with old age, diabetic neuropathy, hypertension, and peripheral vascular disease. Multiple lacunar infarcts secondary to small vessel vasculitis complicating chronic meningoencephalitis due to opportunistic CNS infections (tubercular, fungal etc.) are a rare entity but require elaboration in view of entirely different approach to diagnosis, management, and prognosis. Cryptococcus has CNS predilection due to lack of complementary factors in the CSF. It usually presents as chronic meningoencephalitis, cryptococcoma, and rarely cerebral infarcts primarily in basal ganglia, internal capsule, and thalamus secondary to cryptococcal vasculitis (4%–12% of cryptococcal infections). These infarcts can occur in both acute and later stages of treatment and require initiation/continuation of appropriate antifungal regimen, with early ventricular decompression if hydrocephalus is demonstrated. Conclusion: Neurovascular involvement as multiple lacunar infarcts in chronic cryptococcal meningoencephalitis in an RTR is a rare entity with higher mortality and morbidity, yet reversible with near-complete recovery following early diagnosis and appropriate antimicrobial treatment.


  Multiple Cerebral Abscesses in a Renal-Transplant Recipient: Cladophialophora bantiana and Toxoplasma gondii Co-infection Top


Vivek Sood, K. L. Gupta, H. S. Kohli, Manish Rathi, Vivek Kumar, Raja Ramachandran, Jasmine Sethi

PGIMER, Chandigarh, India. E-mail: viverit@gmail.com

Background: Opportunistic infections by Aspergillus, Cryptococcus, Listeria, and Nocardia lead to brain abscess in renal-transplant recipients (RTRs), unlike an immunocompetent host where etiology is primarily bacterial. Cladophialophora bantiana, a neurotropic dematiaceous fungus, has predilection for immunocompetent patients as well, with mortality of up to 70% despite immediate radical resection along with antifungal treatment. Toxoplasma gondii is also a rare but significant cause of brain abscess in RTRs. Aims of Study: To report an unusual case of middle-aged RTR with multiple brain abscesses secondary to co-infection by C. bantiana and T. gondii. Methods: A 40-year-old male presented with a history of headache and vomiting for 3 days, altered sensorium for 1 day, with no history of fever/seizures/syncope/ear discharge/trauma. He underwent transplant 6 years back with stable graft function, dual immunosuppression i/v/o pulmonary tuberculosis. The patient was drowsy with single ulcerative plaque in the right thigh and had acute allograft dysfunction, creatinine 3 mg/dL, and bland urine. Contrast-enhanced computed tomography brain revealed multiple ring-enhancing lesions in the right frontal lobe with perilesional edema, midline shift with no parameningeal focus. He developed right hemiparesis and status epilepticus requiring supportive therapy, besides stereotactic abscess drainage. Microscopy was suggestive of dematiaceous fungi – C. bantiana. Toxoplasma polymerase chain reaction (PCR) of the aspirate and plasma was positive besides serology, confirming co-infection. He was initiated on amphotericin, flucytosine, voriconazole, pyrimethamine, and sulfadiazine. Thigh lesion also grew fungal elements with brown septate hyphae – possible portal of entry or another metastatic lesion. Results: Toxoplasma brain abscess in renal transplant recipient can result either as primary infection or from reactivation of latent infection and has typical deep-seated ring-enhanced lesions with an asymmetric target sign, variable signal intensity on T2 images in magnetic resonance imaging. Definitive diagnosis requires demonstration of the tachyzoites, but identification of anti-T. gondii antibodies by ELISA and specific nucleic acid amplification by PCR assay is sensitive and specific method for documenting infection. Best outcomes in cerebral phaeohyphomycosis are seen in patients who receive both complete surgical clearance of the abscess and systemic antifungal triple drug regime (amphotericin, flucytosine, and itraconazole). Central nervous system (CNS) toxoplasmosis requires pyrimethamine and sulfadiazine. Overall mortality is around 70% signifying the virulence of C. bantiana attributable to melanin production (scavenges free radicals by phagocytic cells and makes fungus resistant to oxidative/nitrosative stress) and thermotolerance above 40°C. Conclusion: Although rare, both C. bantiana and T. gondii have been known to be associated with CNS abscesses, co-infection has never been reported to date. Stereotactic aspiration/open craniotomy and drainage is imperative to arrive at microbiological diagnosis and early institution of directed therapy.


  Nonrandomized Comparison Between GelPort® and Pfannenstiel Incision as Modality To Place Kidney inside Peritoneum during Robot-Assisted Kidney Transplantation Top


Ruchir Maheshwari, Samit Chaturvedi, Kinjal Banerjee, Mandeep Dhanda, Anant Kumar

Max Super Specialty Hospital, Saket, New Delhi, India. E-mail: ruchir.uro@gmail.com

Background: Robot-assisted kidney transplantation (RAKT) is increasingly being used in patients of end-stage kidney disease (ESRD) with advantages in terms of improved pain scores and lower surgical-site infection rates. Both GelPort® and Pfannenstiel incision are being used to place the graft kidney inside peritoneum. Aims of Study: To compare warm ischemia time (WIT) and functional outcomes between GelPort® and Pfannenstiel incision technique used to place graft kidney inside peritoneal cavity in RAKT. Methods: Between April 2016 and March 2018, 48 RAKTs were performed in our institute, of which GelPort® was used in 21 cases and Pfannenstiel incision in 27 cases. Data were prospectively maintained and compared for patient demography, WIT, rWIT, and creatinine levels at days 7, 30, and 90. Student's t-test was used for statistical analysis. Results: The two patient groups were comparable in age, body mass index, and gender distribution. rWIT was lower in GelPort® group but not statistically significant. Serum creatinine levels were comparable at day 7 (1.81 ± 1.42 vs. 1.67 ± 1.29) but lower at day 30 and 90 in GelPort® group (1.32 ± 0.73 vs. 1.51 ± 0.9, 1.26 ± 0.75 vs. 1.53 ± 0.92); however, none was statistically significant. The results may be affected by three patients in GelPort® group suffering from medical complications leading to suboptimal graft outcomes. The GelPort® group had to bear financial burden of INR 50,000.00 for the device. Conclusion: In this study, no significant difference in outcome was found between the two groups. However, a study with larger number of subjects and longer follow-up is required to reassess outcomes.


  Prospective Nonrandomized Comparison Between Open and Robot-Assisted Kidney Transplantation Top


Ruchir Maheshwari, Samit Chaturvedi, Yasir Qadri, Pragnesh Desai, Anant Kumar

Max Super Specialty Hospital, Saket, New Delhi, India. E-mail: ruchir.uro@gmail.com

Background: Open kidney transplant (OKT) has been a well-established procedure for end-stage renal disease (ESRD). Robotic kidney transplantation (RKT) has been a recent development but is yet to gain popularity. Aims of Study: To compare our first 48 RKTs with OKT done between April 2016 and March 2018. Methods: Data of 48 robotic kidney transplant procedures were prospectively collected and compared with randomly selected 48 cases of OKT done during the same period. All graft kidneys were harvested laparoscopically. Kidney was wrapped in an ice slush jacket and inserted into the abdominal cavity of the recipient through a midline umbilical (21 patients) or Pfannenstiel approach (27 patients). A GelPort® was used to seal the midline incision. The comparison was done using Levene's test for equality of variances and Student's t-test for equality of means. Results: The two groups were comparable in terms of age, sex, duration on hemodialysis, and warm ischemia time. Recipients in RKT group had higher body mass index. There was statistically significant less requirement of perioperative analgesic dose in RKT group. Re-warm ischemia time was longer in RKT group, which was statistically significant. There was slow fall in creatinine levels in RKT group (statistically significant). If we exclude five patients with medical complications, the difference is not statistically significant at days 7 and at 3 months. Conclusion: RKT confers advantage of decreased wound morbidity with similar functional outcomes as compared to OKT in the short term. It looks promising, however, long-term follow-up of large number of patients is needed.


  Unexplained Graft Loss after Second Transplant Top


Kinjal Banerjee, Syed Yasir, Ruchir Maheshwari, Samit Chaturvedi, Pragnesh Desai, Anant Kumar

Max Super Specialty Hospital, Saket, New Delhi, India. E-mail: ruchir.uro@gmail.com

Background: Graft loss post-transplantation is catastrophic event. Aims of Study: To present a case of unexplained graft loss after second renal transplantation. Methods: A 47-year-old male with a history of live-related donor renal transplantation 11 years ago (donor – father), presented with graft failure for pre-emptive second transplantation. Prospective donor was his spouse with the same blood group (O positive). Pretransplant CDC crossmatch and flow cytometry were negative for any reaction. The patient was started on triple-drug immunosuppression and was induced with injection basiliximab 20 mg intravenous on the day of transplant. Left kidney of donor was retrieved laparoscopically and engrafted in left iliac fossa with external iliac vessels in the end-to-side fashion. Immediate diuresis was observed, urine output was 9050 and 6010 ml, and serum creatinine was 1.7 and 1 mg/dL on postoperative day (POD) 1 and 2, respectively. The patient had an unexplained episode of postural hypotension on POD 2, which was managed conservatively. Results: On POD 3, his urine output reduced to 2350 ml and serum creatinine increased to 2.5 mg/dL and developed high blood pressure requiring Nitroglycerine infusion in addition to tablet prazosin 5 mg twice daily and clonidine 100 mcg thrice daily. Color Doppler ultrasound was ordered in view of falling urine output; it revealed absent vascularity of the graft. The patient was immediately taken up for re-exploration which revealed a flabby graft kidney with a bluish hue and collapsed graft artery and vein without any identifiable thrombus. Arterial anastomosis was taken down, kidney flushed with ice-cold HTK solution till clear efflux from gonadal vein and re-anastomosed with restoration of arterial pulsation. However, kidney remained flabby and wedge biopsy bed did not show any bleeding. Biopsy revealed marked acute tubular necrosis with venous thrombosis without any evidence of rejection. His urine output dropped persistently and required hemodialysis support. In view of nonfunctioning of graft kidney, the patient was taken up for open graft nephrectomy on POD 5, intraoperatively, graft kidney was found to be soft, was bluish, and had necrotic patches, and thrombus was found in graft artery. Biopsy revealed renal infarct with arterial thrombosis. Donor-specific antigen (Single Bead) sent on POD 5 was negative for HLA Class I and II antibodies. Conclusion: Sudden loss of vascularity in a previously well-functioning graft without any obvious thrombosis is unexplained. The possibility of vascular thrombo-embolic episode going in segmental vessels cannot be ruled out.


  Rapidly Growing Mycobacteria Causing Subcutaneous Abscess in a Case of Renal Allograft: A Case Report Top


Vajed Mogal, Tushar Dighe, Atul Sajgure

Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. E-mail: drvajedmogal@gmail.com

Background: Mycobacteria are divided into two major groups for diagnosis and treatment: Mycobacterium tuberculosis complex, which comprises M. tuberculosis, and nontuberculous mycobacteria (NTM). NTM can cause pulmonary disease resembling tuberculosis, skin and soft tissue infections, central nervous system infections, bacteremia, and ocular and other infections. Aims of Study: To report the rapidly growing mycobacteria causing subcutaneous abscess in a case of renal allograft. Methods: A 38-year-old male, milk vendor by occupation, was admitted to our hospital as chronic kidney disease stage 5 of unknown etiology on maintenance hemodialysis from past 1 year. The patient underwent live-related renal transplant, mother as donor. His immunosuppression consists of corticosteroids, tacrolimus, and mycophenolate sodium with no induction. He had good allograft function with baseline serum creatinine of 0.8 mg/dl. The patient was asymptomatic till 5 months posttransplant. Results: He presented with local redness without pain and without rise of temperature, 3–5 cm above pubic symphysis over transplant surgical scar. His serum creatinine was 1.3 mg/dl. Ultrasonography and noncontrast computed tomography abdomen showed a subcutaneous abscess of size 3 cm × 2 cm × 4.2 cm that was just below surgical scar. Evaluation of aspirate showed acid-fast bacilli (AFB) on Ziehl–Neelsen stain and culture grew Mycobacterium abscessus species, rapidly growing atypical mycobacteria. The patient was initiated on antitubercular medications: isoniazid, pyrazinamide, ethambutol, and levofloxacin. As per the AFB culture report, clarithromycin was added in addition to previously mentioned antitubercular treatment. Conclusion: Currently, the patient is doing well, with complete resolution of abscess and creatinine of 1.0 mg/dl. His immunosuppression was not altered.


  Recurrence of Primary Disease in Postrenal Transplant: A Rare Case Report Top


Vajed Mogal, Tushar Dighe, Atul Sajgure

E-mail: drvajedmogal@gmail.com

Background: Immunoglobulin-A nephropathy (IgAN) is the most common primary glomerulonephritis (GN) worldwide and 20%–40% of patients progress to end-stage renal failure. IgAN is a primary GN characterized by the dominant or co-dominant diffuse mesangial deposition of IgA, usually IgA1. For these patients, transplantation offers an excellent option for renal replacement therapy. However, immunohistological recurrence develops in as many as 60% of allografts by 10 years after engraftment. Aims of Study: The aim of the study is to report the recurrence of primary disease in postrenal transplant. Methods: Case Report: A 24-year-old male presented in November 2014 with complaints of giddiness, nausea, dyspnea on exertion, and decreased appetite. On presentation, blood pressure (BP) was 160/100 mmHg, serum creatinine was 4.0 mg/dl, ultrasonography (USG) of abdomen suggested of bilateral small, shrunken kidneys (right kidney 7.5 cm × 3.5 cm and left kidney 8.1 cm × 3.7 cm) with loss of corticomedullary differentiation (CMD) and he was diagnosed with chronic kidney disease stage V and chronic GN on conservative management and on irregular follow-up. He presented in January 2015 with serum creatinine 9 mg/ dl; he was initiated on hemodialysis. The patient was on maintenance hemodialysis thrice a week and meanwhile was being worked up for renal transplant, and his father underwent preoperative transplant workup and found to be fit as donor. He underwent live-related renal transplant on June 8, 2015, without induction. On triple immunosuppression therapy: tacrolimus (Tac), mycophenolate sodium, and corticosteroids were used and discharged postoperative day 10 with baseline serum creatinine of 1.1 mg/dl. Results: The patient was asymptomatic for the next 2 years with stable creatinine and Tac levels and lost to follow-up in the next 6 months. Again presented in February 2018 with complaints of fever on and off, decreased appetite, generalized weakness for 15 days. On examination, he was conscious, oriented afebrile with pulse rate - 84/min, BP - 140/80 mmHg, respiratory rate - 20/min, and pallor and edema were absent. Systemic examination was unremarkable. Laboratory investigations showed urine R/M-protein - +++ , red blood cells - 6–8/hpf, pus cells - 2–3/hpf, urine protein-to-creatinine ratio - 3.0 , Hb - 12.5 gm%, total leukocyte count - 10,000 cells/cumm, platelet - 2.3 lakhs/cumm, blood urea - 89 mg/dl, serum creatinine - 5.8 mg/dl, serum Na - 142 mmol/l, serum K - 4.2 mmol/l, serum uric acid - 7.8 mg/dl, serum phosphorous - 5.7 mg/dl, serum calcium - 7.6 mg/dl, HIV, HBsAg, and anti-HCV - negative, USG of transplanted kidney: 11.4 cm × 4.3 cm, normal echogenecity and CMD maintained, blood culture sensitivity - no growth, urine culture sensitivity - no growth, Cytomegalovirus load - negative, BK Virus load - negative. The patient underwent graft biopsy which showed IgAN (recurrent) with 18% glomerular crescents. He was treated with intravenous (IV) pulse therapy (methylprednisolone 1 g) for three days, followed by oral steroids 40 mg/day and tapered 5 mg/week. His triple immunosuppressants were continued. The patient underwent four cycles of plasmapheresis and three doses of IV cyclophosphamide 500 mg. Conclusion: At present, he was asymptomatic, on regular follow-up with serum creatinine of 2.8 mg/dl.


  Unexplained Graft Loss after Second Transplant Top


Kinjal Banerjee, S. Yasir, R. Maheshwari, M. Kumar, Anant Kumar

Max Superspecialty Hospital, Saket, New Delhi, India. E-mail: drkinjalbanerjee86@gmail.com

Background: A 47-year-old male with a history of live-related donor renal transplantation 11 years ago (donor – father) presented with graft failure for pre-emptive second transplantation. Prospective donor was his spouse with the same blood group (O positive). Pretransplant CDC crossmatch and flow cytometry were negative for any reaction. The patient was started on triple-drug immunosuppression and was induced with injection basiliximab 20 mg intravenous on the day of transplant. Aims of Study: To report a case of unexplained graft loss in a patient who underwent second renal transplant. Methods: Left kidney of the donor (laparoscopically retrieved) was engrafted in left iliac fossa with external iliac vessels (end to side). On-table diuresis was observed, urine output was 9 L and 6 L and serum creatinine (S.Cr) was 1.7 and 1 mg/dL on postoperative day (POD) 1 and 2. The patient had an episode of postural hypertension on POD 2 and was managed conservatively. On POD 3, his urine output dropped to 2.3 L, S.Cr rose to 2.5 mg/dL and developed Hypertension requiring Nitroglycerin infusion and tabler prazosin 5 mg BD and clonidine 100 mcg TDS. Color Doppler ultrasonography showed absent vascularity of graft. He was taken up for re-exploration which revealed a bluish flabby graft kidney and collapsed graft artery and vein without any obvious thrombus. Arterial anastomosis was revised after flushing with cold HTK solution. However, kidney remained flabby and wedge biopsy bed showed no bleeding. Biopsy revealed marked acute tubular necrosis with venous thrombosis without any evidence of rejection. His urine output dropped further and he required hemodialysis. In view of above, open graft nephrectomy on POD 5 was done. Results: Intraoperatively, graft kidney was soft, was blue, and had necrotic patches and thrombus was identified in graft artery. Biopsy revealed renal infarct with arterial thrombosis. Donor-specific antibody (Single Bead) was negative for HLA class I and II antibodies. Conclusion: Sudden loss of vascularity in a previously well-functioning graft without any obvious thrombosis is unexplained. The possibility of vascular thromboembolic episode going in segmental vessels cannot be ruled out.


  Living Donor Renal Transplantation without Any Induction Immunosuppression in Spousal Donors: Our Experience Top


Raghuramachandra Bhat, Sajith Narayanan, N. A. Ismail, Feroz Aziz, Benil Hafeeq

Aster MIMS Hospital, Calicut, Kerala, India. E-mail: raghurambhat.r@gmail.com

Background: Renal transplantation in India is primarily driven by living-related donation; parents and spouse constitute 70% of donors in India. Some centers use induction immune suppression (IIS) for all spousal transplants considering it as an immunologically high-risk scenario. Our protocol is to give induction only if recipients are of immunologically high risk from anti-HLA antibody perspective. Aims of Study: To compare the incidence of rejection in the 1st posttransplant year, graft loss, and patient loss among patients who underwent renal transplantation from parental-donor and spousal-donor without IIS. Methods: It is single center-based, a retrospective study of living donor renal transplantation of parents and spouse (wife) as donors. Patients from January 2006 to December 2016 were included. We excluded patients with induction therapy, ABO-incompatible transplantation and female recipients with husband-donors who had pregnancy as sensitizing event, patients with lost or irregular follow-ups. Patients' baseline characteristics, rejection by 1 year posttransplantation, graft loss, and patient loss were analyzed. Results: Out of 361 patients, 154 belonged to parental-donor and 75 patients to spousal-donor groups with an average follow-up of 2009 ± 998 and 1740 ± 922 days, respectively. The mean age of recipients was significantly lower in parent group (27.8 ± 6.9 years) than in spouse group (45.6 ±7.9 years). Donor age was much higher in parent group (50.4 ± 7.3 years) than the spouse group (38.4 ± 7.8 years). Spouse group received kidney with mean glomerular filtration rate (GFR) of 49 ± 43.3 ml/min which was significantly higher than the parent donor group 38.9 ± 9.3 ml/min (P = 0.02). The incidence of acute rejections in the first posttransplant year was comparable with 18% and 17% in parent-donor and spouse-donor groups, respectively. Parental-donor had more acute cellular rejection and mixed rejections, Antibody mediated rejection rejections were more common in spouse-donors. Patient loss and death-censored graft loss were comparable in both groups. Five-year patient survival was 95% and 92% and 5-year death-censored graft survival was 87% and 91% in parental-donor and spousal-donor groups, respectively. Conclusion: Spousal kidney donation can provide more age compatible transplantation with better GFR without augmented IIS in patients with low immunological risk, leading to better long-term graft and patient survival when compared to traditionally considered low-immunological risk parental kidney donation.


  ABO-Incompatible Transplantation without Routine Induction Immunosuppression: Our Experience Top


Anjaney Yadur, Sajith Narayanan, Feroz Aziz, N. A. Ismail, Benil Hafeeq

Malabar Institute of Medical Sciences, Calicut, Kerala, India. E-mail: dranjaney@gmail.com

Background: Transplantation across ABO blood group (ABOI-Tx) has facilitated more living-donor kidney transplantation by increasing donor pool. Augmented immunosuppression (IS), financial overburden, logistics of pretransplant preparation, and need of multidisciplinary team have made ABOI-Tx impractical to many transplant centers. Aims of Study: To analyze the outcome of our series of 35 consecutive ABOI-Tx patients who underwent transplantation without routine thymoglobulin or IL2R-blocker induction. Methods: Our study is a retrospective analysis of patients who had undergone ABOI-Tx from two tertiary care centers in Calicut having the same IS protocol. Anti-A and anti-B titers < 1:512 by Gel Method (Bio-Rad) were accepted for desensitization. All patients underwent CDC cross-match, flow cross-match, and Luminex-anti-HLA antibody screen. Desensitization regimen included rituximab 200 mg on day 21, triple IS-prednisolone 10 mg, MMF 1000 mg, and tacrolimus 0.05 mg/bodywt from day 14 and plasma-exchange (PLEX) 3–4 sessions from day 7 to attain titer of 1:8 before transplantation. Transplantation was done without induction IS. Results: Thirty-five patients underwent ABOI-Tx from both centers. Twenty-eight recipients were male. Average age was 36.22 ± 9.3 years with follow-up of 426 ± 335 days. Eleven donors were spouse, 18 were parents, four were siblings, one was mother in law, and one was brother in law. The average age of donor was 47.08 ± 9.2 years. Thirty-one patients have normal functioning transplant with creatinine 1.23 ± 0.2 mg/dL. Three patients were lost, one on postoperative day (POD) 3 due to ACS and second on POD 22 due to fungal sepsis while the other on POD 5 due to ACS. One graft loss occurred due to post-transplant HUS with no evidence of rejection. Of the functioning allograft recipients, one had cellular rejection which resolved with pulse steroid, and one developed hemolytic uremic syndrome due to calcineurin inhibitor which recovered with PLEX and switch to non-CNI based IS. Three patients developed antibody mediated rejection which was reversed with PLEX and augmentation of IS. Three patients had cytomegalo virus viremia and three patients had BK virus viremia, all resolved with treatment and tailoring of IS. Conclusion: ABOI-Tx is a good option if done with proper patient selection and pretransplant immunomodulation. Induction IS is not needed with a favorable immunological profile as it can bring down the cost and infectious complications.


  The Clinical Utility of 2-deoxy-2-(fluorine-18)fluoro-D-glucose integrated with computed tomography in Suspected Infections in Renal-Transplant Patients Top


Sunil Patil, N. K. Hase, Tukaram Jamale, Divya Bajpaye, Sunita Sonawane

Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: drharrison4u@gmail.com

Background: Renal-transplant recipients are susceptible to a diverse range of infections. Various presentations of the same lead to challenges in diagnosis. Further, the adequate duration of therapy is elusive. It is established that 2-deoxy-2-(fluorine-18)fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) has high diagnostic accuracy for detection and anatomic localization of both infections and malignancies. However, its utility in posttransplant setting remains to be elucidated. Aims of Study: To evaluate the utility of 18FDG-PET CT in renal-transplant patients. Methods: This retrospective analysis includes evaluation of 29 18F-FDG PET/CT scans in 21 postrenal transplant patients from 2012 to 2018. 18FDG-PET/CT scan was done to locate the focus of infection, to confirm resolution of infection, and to decide about discontinuation or alteration of treatment. Results: A total of 21 patients with 15 males and 6 females were studied. The mean age was 33.5 ± 7.4 years. Seventeen of 21 were live donor transplants (13 related and 4 unrelated including one swap transplant) and four were deceased donor transplants. Antibody induction with injection anti thymocyte globulin was given in 10 patients. Most common maintenance immunosuppression used was tacrolimus + mycophenolate + prednisolone in 18 patients with azathioprine in two patients and cyclosporine and azathioprine in one patient. Six patients had acute on chronic graft dysfunction and remaining 15 had acute graft dysfunction, three patients had new-onset diabetes after transplant, and two had urinary tract abnormality as comorbidities. Indications for FDG-PET-CT were recurrent pyelonephritis in 14 patients, three had pyrexia of unknown origin, two had musculoskeletal problems, one had dactylitis with fever and skin nodules, one had significant weight loss, anemia, and thrombocytopenia with hyperuricemia. None of the patients had allograft rejection. Of 29 scans, 17 scans did not show any abnormality, of which four patients were continued on the same treatment in view of persistent symptoms and in remaining patients the ongoing treatment was stopped. Out of the remaining 12 patients who showed abnormality, antibiotic therapy was changed in seven patients, four patients were started on antitubercular therapy, and one was added on antifungal treatment. Conclusion: 18F-FDG PET/CT scan serves as a vital tool in diagnosis and management of infections in renal-transplant recipients.


  Early Surgical Complications in Deceased Donor Renal-Transplant Recipients due to Vascular Abnormalities in Donor Kidney Top


P. Srinivas, Y. Manjusha

Department of Nephrology, Gandhi Medical College, Secunderabad, Telangana, India. E-mail: swathivasu194@gmail.com

Background: Kidney transplant remains one of the pioneer branches of solid organ transplant worldwide. With refinement of surgical techniques, especially vascular anastomosis principles, the incidence of surgical complications remains low. However, they still remain important posttransplant complications in both early and late periods. One of the important causes of surgical complications is the vascular anomalies or abnormalities in the donor kidney. Aims of Study: we report two cases with peritransplant complications due to underlying vascular abnormality. Methods: Case 1: A 36-year-old male with kidney disease CIN on dialysis 5 years through right brachiocephalic arteriovenous fistula is the recipient. B positive Hb was 10.8 gm, total leukocyte count (TLC) was 9000, platelet was 94,000. Donor was a 30-year-old male, nonhypertensive, nondiabetic, died due to road traffic accident (RTA), and creatinine of 0.9 mg/dl. Graft: warm and cold ischemia time was 1.5 min and 4 h 40 min, respectively. There was a short renal artery, short renal vein with porous sieve-like at the renal sinus with three openings on the anterior side and one on posterior side. Intraoperative events were difficulty in anastomosing renal vein and accelerated hypertension. On-table diuresis started. Hypotension developed on day 1. Doppler on day 1, 2 and 3 was within normal limits (WNL). Noncontract-enhanced computed tomography (NCCT) on postoperative day (POD) 1 showed perirenal collection above graft kidney 11 cm × 3 cm posteroapical. Doppler on POD 4, 8, and 13 showed altered spectral pattern with reduced diastolic flow. Doppler on POD 28 showed normal flow with resolving hematoma. The patient did not require any renal replacement therapy. The patient later developed wound gaping with continuous leakage of fluid and died due to pneumonia and sepsis. Results: Case 2: A male patient aged 44 years, native kidney disease being chronic glomerulonephritis, chronic kidney disease 5 D on maintenance dialysis for 3 years, access right radial artery-cephalic vein arteriovenous fistula is the renal recipient. His blood group is B positive, Hb 13.4 gm, TLC 10,200, and platelet count 1 lakh. Donor Details: A 54-year-old male, nondiabetic, nonhypertensive, died due to RTA. His serum creatinine was 1.3 mg/dl. Graft Details: LCM was negative, and warm and cold ischemia time was 3.5 min and 9 h and 30 min, respectively. Donor kidney has accessory lower pole artery. Intravenous methyl prednisolone and basiliximab are given as induction therapy. Intraoperative Events: Difficulty in anastomosing accessory renal artery, hypotension and arrhythmias, and atherosclerotic plaques in internal and external iliac arteries of recipient. There was no on-table diuresis. Postoperatively, he started on triple immunosuppression. Continuous hemorrhagic drain of about 4–8 L on day 1 was observed. Fluid Analysis: Creatinine of fluid was same as serum creatinine and RBC were present. Postoperative renal Doppler: On POD 0, complex fluid collection in the perinephric and retroperitoneum 10 cm × 10 cm ×3 cm, likely hematoma was observed. On POD 3, it was found to be WNL. On POD 8, graft kidney was showing features suggestive of abscess. NCCT of abdomen: On POD 2, mild perinephric collection was noted along the posterior aspect of graft kidney with no indentation on the renal cortex. The patient required RRT from day 6 and later died due to pneumonia and graft abscess. Conclusion: Presence of renal vascular abnormalities and difficult surgery should caution against the development of perioperative hemorrhagic complications. CT would be more sensitive in the detection of perinephric hematoma than the color Doppler.


  C4D-Negative Isolated Vascular Rejection (Early Active Antibody-Mediated Rejection)-Successful Treatment with Plasmapheresis and High-Dose Intravenous Immunoglobulin in Two Hepatitis C Seropositive Deceased Donor Renal-Transplant Recipients Top


Pradeep Khandavalli, Manjusha Yadla, Megha S. Uppin

Gandhi Medical College, Secunderabad, Telangana, India. E-mail: pradeep250888@gmail.com

Background: Antibody-mediated rejection (ABMR) is common cause of allograft failure after kidney transplantation. Among patients who recover, acute rejection episodes have negative impact on long-term graft survival. Acute rejection is a predictor of interstitial fibrosis and tubular atrophy (IFTA). The diagnosis of ABMR requires morphologic evidence, circulating donor-specific antibody (DSA), and immunologic evidence of an antibody-mediated process. Patients with the first two criteria but no evidence of DSAs are considered to be “suspicious” for ABMR and are typically treated as patients with ABMR. Aims of Study: We report two cases with ABMR during 1st week posttransplant from a deceased donor and successfully treated with plasmapheresis and high-dose intravenous immunoglobulin (IVIg). Methods: Case 1: A 30-year-old female HCV-positive presumed CIN–CKD 5(D) underwent deceased donor renal transplantation. Donor was 41-year-old female who met with road traffic accident (RTA). LCM was negative, warm ischemic time (W.I.T) was 2 min, and cold ischemic time (C.I.T) was 7.25 h. IV MPS and IL2-RA basiliximab 20 mg were given as induction. The patient had intraoperative hypotension, recovered on day 0. On-table dieresis was present. The patient was started on triple immunosuppression. The patient developed delayed graft function on day 3 and Doppler study was normal. Renal biopsy done on postoperative day (POD) 5 was suggestive of acute tubular necrosis, POD 12 suggestive of acute tubulointertstial nephritis with probable cellular rejection. He started on ATG and also the patient was given plasmapheresis and high-dose IVIg. Renal biopsy on day 19 revealed isolated vascular rejection (C4D negative). The patient recovered on day 27. At present, the patient is 9 months posttransplant with stable graft function. Results: Case 2: A 27-year-old male HCV-positive patient presumed CIN–CKD5(D) underwent deceased donor renal transplantation. Donor was 24–year-old male who met with RTA. LCM was negative, W.I.T was 3.5 min, and C.I.T was 7.5 h. IV MPS and IL2-RA basiliximab 20 mg were given as induction. The patient had intraoperative hypotension and recovered on day 0. On-table dieresis was present. The patient was started on triple immunosuppression. The patient developed delayed graft function on day 5 and Doppler study was normal. Renal biopsy on day 8 revealed isolated vascular rejection (C4D negative). He started on plasmapheresis and high-dose IVIg. The patient recovered on day 23. At present, the patient is 6 months posttransplant with stable graft function (serum creatinine - 1.1 mg/dl). Conclusion: (1) Early occurrence of C4D-negative isolated vascular rejection without peritubular capillaritis (ABMR) is rare. (2) Timely identification and appropriate management would yield better graft outcomes.


  Tuberculous Myositis of Erector Spinae as Presenting Manifestation of Disseminated Tuberculosis in Renal-Allograft Recipient Top


Shabana Nazneen, Manjusha Yadla

Gandhi Medical College, Secunderabad, Telangana, India. E-mail: drjavedsh@gmail.com

Background: Tuberculosis (TB) is an important opportunistic infection encountered in postrenal-transplant recipients in developing countries. It ranges from 1.2% to 12%, and in India, the incidence of TB in renal-allograft recipients is 12.3%, among which extrapulmonary TB 51.8%. About 3%–10% musculoskeletal involvement was observed. Tuberculous myositis is one of the rare manifestations in general population but should be considered in immunocompromised patients as differential diagnosis. Aims of Study: Paraspinal abscess can be the manifestation of TB myositis. A 38-year-old female underwent emotionally related live renal transplant on May 2016. Methods: The patient was diagnosed with pulmonary TB at 7th month of posttransplant period and started on antitubercular drugs, ATT, and completed category 1. Six months later, she presented with a history of swelling in the left subscapular region gradual in onset, with mild pain in posterior cage and low-grade fever, and on examination, the patient had nontender, nonfluctuant swelling around 10 cm × 3 cm to the left of lower dorsal spine and no history of weakness of muscles, and on evaluation, total leukocyte count was normal and ultrasound back was done and started on intravenous antibiotics and continued for 1 week. Meanwhile, the patient developed right supraclavicular swelling and swelling over incision site, and on examination, supraclavicular lymph nodes were palpable, matted. Further workup was done, fine-needle aspiration cytology (FNAC) of supraclavicular, incision site lymph node was done, magnetic resonance imaging (MRI) dorsolumbar spine was done, sputum for acid-fast bacilli was sent. Results: Fine needle aspiration cytology of the right supraclavicular lymph nodes was suggestive of granulomatous lymphadenitis, whereas FNAC of incision site lymph node suggestive of nonspecific inflammation. MRI dorsolumbar suggestive of hyperintense fluid collection in the dorsal region on T2W measuring 11, 3.6 cm along left paraspinal muscle, hypointense internal septations in lower aspect, mild T2W hyperintensity in surrounding muscles, vertebral bodies, intervertebral discs are normal, spinal canal and cord normal suggestive of Kochs etiology Paraspinal abscess was drained as there was no response to antibiotics. Pus drained did not yield growth on microbiology. Meanwhile, she was placed on antituberculous treatment again 2 months after which the patient showed clinical improvement. Graft function remained stable. Suture line nodules were excised. On histopathology, this revealed nonspecific inflammation. Conclusion: TB pyomyositis is rare but to be suspected in patients presenting with backache paraspinal swelling and history of TB. Disseminated multidrug-resistant TB should be treated promptly and suture line TB should be managed appropriately.


  15 Years' Experience of Tackling Postrenal Transplant Polyoma Virus Nephropathy: Lessons Learned Top


Ahmed Waheed Kashif, Ashish Sharma, Ashwani Kumar, Gargi Kapatia, Deepesh Kanwar, Vivek Kumar, K. L. Gupta, Ritambhra Nada

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: ahmed.kashif23@gmail.com

Background: Polyomavirus nephropathy (PVN) has emerged as an important cause of renal transplant failure. Although the disease has been around for a long time, not much data are available especially from the Indian subcontinent. In this study, which is the largest single-center, retrospective study, we have attempted to quantify the timing, risk factors, evolution of renal function, relationship with immunosuppressant regimen, and transplant graft outcome in renal transplant recipients with PVN from our center. Aims of Study: To summarize the clinicopathological findings of PVN, evaluating demographic profile, incidence, risk factors, treatment, and transplant outcome of PVN and look for any change in trend. Methods: A retrospective analysis was conducted among kidney-transplant recipients, who were histologically proven PVN cases, at PGIMER, Chandigarh, from February 2003 to February 2018 (15 years). Patients' demographic data, information on kidney transplantation, immunosuppressive therapy, polyomavirus infections, and allograft outcomes were retrieved and analyzed. Results: Altogether, 2300 renal transplants were carried out at our center during the 15 years (2000 live donor, 300 deceased donors). Of these 2300 cases, 80 were histologically proven cases of PVN (3.47%). Of these 80, 36 recipients (30 males, 06 females) were regularly followed up for a median of 38.5 months (range 3–166 months, standard deviation 45.5). The median age of the recipients was 33.5 years (range 13–57), while the donor age ranged from 28 to 59 years, median = 41.5 years. The upper level of serum creatinine in this cohort ranged from 1.1 to 22 mg/dl, with a median of 2.21 mg/dl. Majorly, the patients received either tacrolimus-based regimen (n = 17) or cyclosporine-based regimen (n = 15) or both (n = 4). Typically, intervention consisted of reducing calcineurin inhibitors exposure before or after antimetabolite dose reduction, withdrawal of one agent from the triple-therapy regimen, or switching between agents within a therapeutic class. Nearly 28% patients had poor outcome (8 graft loss, 2 died as a result of complications). Conclusion: In comparison to our previous study, there is a decline in PVN cases which could be due to different study designs. There is no significant difference between cyclosporine- and tacrolimus-based regimen.


  MIRDEEP: Potential Regulation of Deep Coding Region of HLA Genes by MicroRNAs in Renal-Allograft Recipients Top


Pradeep Jaswani, R. K. Sharma, Narayan Prasad, Suraksha Agrawal1

Departments of Nephrology and 1Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raibareily Road, Lucknow - 226 014, Uttar Pradesh, India. E-mail: pradeep.jaswani3@gmail.com

Background: MicroRNAs (miRNAs) are potent regulators of class I and class II HLA genes by binding to promoter regions as well as coding region of the genes thus determining their expression pattern. Quantification of miRNAs with corresponding target gene has been functional relevance in renal diseases and they might represent a new class of biomarkers for frequent evaluation of renal-allograft status. Aims of Study: To analyze the potential role of Let7e, miR23a, miR15b, and miR195 by regulating coding region of HLA-A, HLA-B, HLA-DQ, and HLA-DR, respectively, in identifying severe allograft rejection. Methods: miRWalk database revealed that miRNA-Let7e, 23a, 15b, and 195 compliment with coding region of HLA-A, HLA-B, HLA-DQ, and HLA-DR, respectively. Total RNA was isolated from whole blood followed by cDNA preparation by reverse transcription. SyberGreen Based Real-time-PCR was performed for all four candidate miRNAs with their corresponding target gene in 84 renal graft recipients. GAPDH and U6 RNA were used as internal controls. Thirty-eight patients were diagnosed with renal allograft rejection, 13 with Banff 4-/II/III rejection, 12 with Banff-2 antibody-mediated rejection, 6 patients with a combination of cellular/AMR, and 7 patients develop other acute rejection. Forty-six patients were determined with stable graft functions. The relative expression level of mRNA was analyzed by 2−ΔΔCt method. Statistical analysis was performed using SPSS v. 21. Results: Expression data evident that Let7e positively regulates HLA-A expression, while downregulation of miR23a, miR15b, and miR195 significantly upregulates HLA-B, HLA-DQ, and HLA-DR, respectively, in blood of renal-allograft rejection patients compared with nonrejection group. Upregulation of Let7e (3-fold) would enhance HLA-A expression up to 87-fold, while downregulation of miR23a, miR15b, and miR195 results upregulation of HLA-B expression (2-fold), HLA-DQ (30-fold), and HLA-DR (3-fold) respectively. Higher expression of HLA-A and B enhances CD8+ T-cells which may results T-cell-medicated vascular rejection (Banff-4 II/III) and higher expression of HLA-DQ and DR promotes CD4 expression which may develop B-cell antibody-mediated renal-allograft rejection (Banff-2). Kaplan–Meier analysis showed concordance with expression results, i.e., decreased in the graft survival during downregulation of miR23a, miR15b, and miR195 and higher expression of Let7e with elevated HLA-A, B, DQ, and DR. Conclusion: The combined quantification of Let7e, miR23a, miR15b, and miR195 with corresponding target genes HLA-A, HLA-B, HLA-DQ, and HLA-DR may help to better identify renal allograft rejection, especially TCMVR and ABMR after renal transplantation in a precise and clinically applicable way.


  Two Rare Presentations of Tuberculosis in Postrenal-Transplant Recipients Top


S. Murugesh Anand, M. Edwin Fernando, N. D. Srinivasaprasad, S. Sujit, K. Thirumalvalavan, R. Vivek Praveen

Government Stanley Medical College Hospital, Tamil Nadu Dr. M. G. R. Medical University, Chennai, Tamil Nadu, India. E-mail: drmurugesh86@gmail.com

Background: Despite major advances in the field of medicine, diagnosis of tuberculosis (TB) remains a great challenge to the treating physician. TB has huge diversified clinical presentations with unusual and rare forms of organ involvement. TB can affect any of the organ system in the body. Owing to vague and nonspecific clinical features, the diagnosis of TB can be missed or delayed even in areas with high incidence. Aims of Study: Here, we present two rare presentations of TB in postrenal-transplant recipients. Methods: Case 1: A 31-year-old male underwent ABO-compatible, live-related renal transplantation on August 26, 2017. No induction agent was used. He was discharged with triple immunosuppression with a discharge creatinine of 1.09 mg%. Eight months after transplant, he had fever and cellulitis right foot. Doppler of the right lower limb revealed subcutaneous edema with myositis. Biopsy from the skin around cellulitis was taken and sent for histopathological examination (HPE). Simultaneously, as the cellulitis worsened, fasciotomy was done and minimal pus was drained and was sent for Gram staining and acid-fast bacilli (AFB) stain. HPE of skin and AFB stain of pus revealed plenty of Mycobacterium tuberculosis bacilli. CB NAAT standard short form from the pus revealed rifampicin sensitive bacilli. The patient was initiated on anti tubercular therapy. The patient improved clinically with antituberculous drugs. Results: Case 2: A 30-year-old male underwent ABO-compatible live related renal transplant on September 08, 2016. No induction was given. He was discharged with triple immunosuppression. Six months after transplantation, he had fever, dyspnea, productive cough, and weight loss. Lungs showed bilateral coarse crepitations. Hb was 6.9 gm%, platelet was 26,000, creatinine was 8.1 mg%, urea was 271 mg%, potassium was 5.95, bilirubin was 2.1 mg%, and LDH was 874 IU/L. Urine: blood 3+ , protein 1+. Peripheral smear-fragmented RBCs and Thrombocytopenia. In view of graft dysfunction, he was dialyzed and underwent allograft biopsy which revealed extensive TMA, severe tubular injury, C4d negative, I1, T1, V0, PTC0. Sputum AFB: 3+. CT Chest-Bilateral Miliary mottling/cavity. ATT was initiated. The patient improved clinically with ATTand creatinine decreased to 1.8 mg%. Nineteen days after ATT initiation, the patient had ATT-induced severe liver injury and hence first-line ATT was stopped and second-line drugs were initiated. The patient developed respiratory failure and had sudden cardiac arrest on April 5, 2017. Conclusion: TMA associated with TB in a posttransplant recipient is rarely described. The mechanism of TMA induced by TB infection is not clearly understood, but considered secondary to endothelial injury. Similarly, TB involving skin and soft tissue without a pulmonary focus is not common.


  Comparing Outcome of Kidney Transplant in Diabetic, in Those Who Develop New-Onset Diabetes after Transplant and in Nondiabetic Subjects Top


Mita Shah, Pawan Deore, Hepal Vora, Zaheer Virani, Prashant Rajput, Bharat Shah

Global Hospital, Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: The incidence and prevalence of diabetes are increasing and it is the main cause of chronic kidney disease (CKD). Kidney transplant is the best form of renal replacement therapy for end-stage renal disease. How do the results in diabetics, pre-existing diabetes, or new-onset diabetes after transplant (NODAT) compare with the results in nondiabetic? Aims of Study: To assess the outcome of kidney transplant in diabetic, in those who develop NODAT and in nondiabetic subjects. Methods: All renal transplants performed from August 1, 2013, to June 30, 2018, at our center were included. These patients were divided into three groups: diabetic, NODAT, and nondiabetic. Induction and maintenance immunosuppression were similar in all three groups. Prophylaxis against opportunistic infection included co-trimoxazole and valganciclovir. The patient survival and graft survival were the primary outcomes. Cardiovascular complications, infections, and malignancy were secondary outcomes. Results: Of 290 patients, 89 (31%) were diabetic, 85 (29%) were NODAT, and 116 (40%) were nondiabetic. The 1-, 3-, and 5-year patient survival in diabetic subjects was 92%, 81%, and 81%, respectively. It was 93%, 92%, and 92% in new onset diabetes after transplant and 95% in nondiabetic subjects (P < 0.05). The 1-, 3-, and 5-year death-censored graft survival in diabetic subjects was 95%, 92%, and 92%. It was 93%, 92%, and 87% in NODAT and 97%, 96%, and 96% in nondiabetic subjects. Infections (particularly urinary tract infection and tuberculosis) and cardiovascular events were significantly higher in diabetic and NODAT. Conclusion: Our study shows that diabetes is an important risk factor determining outcome of transplant. Even NODAT increases the risk of complications after transplant.


  Our Experience with Dual Kidney Transplant Top


Bharat V. Shah, Menal Wali, Pawan Deore, Hepal Vora, Zaheer Virani, Prashant Rajput

Global Hospital, Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: Use of expanded criteria donor (ECD) kidney is associated with poor outcome. This is largely due to inadequate renal mass being transplanted. Dual kidney transplantation (DKT) by providing adequate renal mass allows utilization of ECD kidneys. This can to some extent alleviate the disparity between available donors and potential recipients.Aims of Study: To describe our experience of dual kidney transplants performed with ECDs. Methods: In four recipients (3 males, 1 female, age 34–63 years) with end-stage renal disease, both kidneys from ECDs (three over the age of 60 with death resulting from a stroke, and one from an 18-month-old child) were transplanted. In all four cases, lymphocyte-depleting agent was used for induction and standard triple immunosuppression (CNI, AZA/MMF, and PSN) for maintenance. All patients received valganciclovir and SMX-TMP prophylaxis. Results: In one patient, there was delayed graft function, while in other three cases, there was an immediate graft function. The graft function was excellent (serum creatinine <1.2 mg/dl) in all four cases. In the recipient of kidneys from pediatric donor, kidneys grew to adult size in 6 months. In none of the four cases, there was any episode of rejection. Conclusion: Our limited experience suggests that kidneys from ECDs should not be rejected. Rather, dual kidney transplant should be performed. This provides adequate nephron mass with excellent renal function. Provision of high renal mass probably reduces the risk of rejection.


  A Fatal Case of cerebral aspergillosis in Postrenal-Transplant Patient Top


Manisha Gupta, T. N. Dhole, R. S. K. Marak

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: dreamsmaterialise@gmail.com

Background: Transplant recipients are among the most significant subgroups of immunosuppressed hosts at risk for invasive aspergillosis. Prevalence and outcome of fungal infection in solid organ transplantation (SOT) vary by type of organ transplanted. While kidney recipients are at the lowest risk (ranging from 0.4% to 5%), liver and heart recipients have moderate risks of acquiring this fungal infection. The highest incidence of aspergillosis is observed among lung-transplant recipients. Aims of Study: In this report, we present a fatal case of invasive cerebral aspergillosis, which is rarely seen in renal-transplant recipients. Methods: A 61-year-old female was admitted with the complaints of seizures of 4 episodes for 4 days and fever low-grade on and off for 3 days. The patient is a follow-up renal transplantation, and date of transplantation was February 4, 2014, on triple immunosuppression. The patient had a stormy posttransplant course with graft dysfunction and a cerebrovascular accident left hemiparesis (infarct in May 2014) and treated conservatively. On physical examination, pallor was present. Chest examination showed bilateral crepts, and rhonchi were present, central nervous system (CNS) examination revealed altered sensorium. On investigations: total leukocyte count : 15, 000/μL, DC = N88/L10, HB – 7.6 gm%, S. creatinine – 2.1 mg% S. albumin – 3.3 g% , S. total proteins – 5.8 g%. Magnetic resonance imaging showed ring-enhancing lesion in the right high frontal lesion. Brain pus microscopy showed a plenty of pus cells, hyaline septate fungal hyphae with acute angle branching. Culture on sabouraud dextrose agar showed growth of Aspergillus fumigatus. Voriconazole was started however patient developed lower respiratory track infection and continued to have fever. Subsequently, the patient condition worsened and succumbed to illness. Results: The pathophysiology of the cerebral aspergillus infection implicates an infective vasculopathy-mediated septic infarction or hemorrhage; causing infectious cerebritis that evolves into an abscess culture of clinical specimens to isolate the etiologic fungal agent remains the gold standard for diagnosis. This case highlights the need for early diagnosis, clinical suspicion, and aggressive medical-surgical co-management for invasive fungal disease of the CNS when possible. Conclusion: Invasive aspergillosis poses a serious challenge for physicians. Voriconazole is the treatment of choice, but resistance is not uncommon. It is critical to monitor therapeutic drug levels, where available, during voriconazole therapy to ensure clinical efficacy and decrease adverse effects.


  Management Strategy of Vascular Access-Related Major Complications in Hemodialysis Patients Top


Yashpal Thakur, Naveen Kumar, Sanjoy Kumar Surekha

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: dryashthakur@gmail.com

Background: The arteriovenous fistulae (AVFs) remain the ideal vascular access for patients on maintenance hemodialysis. Many of these complications are potentially dangerous and need aggressive surgical management. Aims of Study: Here, we aimed to study the clinical presentation and surgical management of the complications associated with surgically created AVF in patients on maintenance hemodialysis. Methods: This retrospective study was conducted on patients who underwent surgical intervention for various complications related to AVF created at our center or referred to our center for the management of complications. We have excluded outflow venous stenosis, asymptomatic aneurismal dilatation, and failure to maturation from our analysis. Results: A total of 210 complications seen in 3100 AVF created from 2001 to 2017 requiring surgical intervention. Preoperatively, complications were evaluated with ultrasonography Doppler or angiography (computed tomography/magnetic resonance) in selected cases. Most common complication was pseudoaneurysm (PA) (n = 128, 68.2%), followed by venous hypertension (n = 40, 19.04%), complicated (skin ulcer/bleeding/infection) aneurismal dilatation (n = 25), steal phenomenon (n = 12, 10%), pulmonary hypertension (n = 3), and cardiac failure (n = 2). PA was most common at anastomosis site followed by vein puncture site. Fistula could be salvaged only in 15%. Brachiocephalic fistula (BCF) or Brachiobasilic fistula complications required repair of artery with or without sephanous interposition graft when PA involved anastomotic site. Venous hypertension involving BCF was managed with ligation of outflow vein or angiographic balloon dilatation. Success of angiographic management was 55% with 80% had recurrence of symptoms with median follow-up of 11 months. Conclusion: PA is the most common major complication of AVF and may require challenging vascular reconstruction if they involve the anastomotic site of elbow AVF. Angiographic balloon dilatation is a viable option for short-segment outflow venous stenosis. After major complication, salvage rate is low.


  Nephrolithiasis in Potential Live-Related Kidney Donors: Prevalence, Management, Long-Term Outcome of Donor and Recipient Top


Yashpal Thakur, Naveen Kumar, Sanjoy Kumar Surekha

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: dryashthakur@gmail.com

Background: The use of computerized tomography angiography for donor evaluation has resulted in the increased detection of incidental nephrolithiasis in living renal donor candidates. Aims of Study: To report the epidemiology of asymptomatic renal stones in healthy live-related potential donors and management and long-term outcome of kidney recipient with asymptomatic stones in donor. Methods: 2500 potential donors, between 2000 and 2017, were evaluated for the presence of asymptomatic renal stones. They were subjected to abbreviated metabolic panel for stone disease along with a detailed clinical history. Donors with stone >15 mm, significant metabolic abnormalities, and presence of associated risk factors for recurrent stone disease were rejected; finally, 49 donors with stones proceeded for donation with stone size of 2–15 mm (Group I: Stone <4 mm, n = 21; Group II: stone 5–15 mm, n = 28). Patients of Group I were accepted for donation with stone in situ whereas, patients of Group II were treated for stones before donation. Records were analyzed for recipient outcome with special attention to stone events, as well as outcome of donor in terms of stone recurrence in residual kidney. Results: Prevalence of asymptomatic renal stone in potential donors was 4%. Mean age of the donor was 45.2 ± 9.5 years with mean glomerular filtration rate of the transplanted kidney being 39 ± 3.5 ml/min. In Group II, 14 had extra corporeal shock wave lithotripsy, 12 had standard medical short forms, and 2 had percutaneous nephrolithotomy before donation. In Group I, follow-up imaging revealed that eight, four, and one patients had residual stones (all <4 mm) at 1 month, 3 months and 1 year, respectively; similarly, in Group II, five, three, and one patient had residual stone (<6 mm). Except one, none of the recipients had stone-related events in posttransplant period. One patient of Group II required ureteroscopic stone retrieval in the posttransplant period. The mean serum creatinine of the recipients at 3 months and 1 year was 1 ± 0.15 and 1.30 ± 0.4 mg/d respectively, with a mean follow-up of 8.5 years. Donors did not show any stone recurrence in the residual kidney. Conclusion: Donors who donated the stone-bearing kidney fared equally well in terms of recurrence of stone in residual kidney. Transplantation of kidney with small asymptomatic renal stone in situ can safely done with adequate postoperative follow-up.


  Role of Serum Neutrophil Gelatinase-Associated Lipocalin for Prediction of Acute Graft Dysfunction after renal transplantation Top


Ashok Ramasamy, Shankar Prasad Nagaraju, Ravindra Prabhu Attur, Dharshan Rangaswamy, Indu Rao

Kasturba Medical College, Manipal, Karnataka, India. E-mail: cyber88bob@gmail.com

Background: Neutrophil gelatinase-associated lipocalin (NGAL) is a useful biomarker for the early diagnosis of acute kidney injury (AKI) as shown in various studies. The objective of our study was to re-evaluate the role of serum NGAL in predicting acute graft dysfunction in the early postkidney-transplant period. Aims of Study: To evaluate the role of serum NGAL in predicting acute graft dysfunction in the early postkidney-transplant period. Methods: This was a single-center prospective study conducted over a period of 6 months from January 2018 to August 2018. All patients (n = 30) who underwent a renal transplant during this period were included in the study. After obtaining institutional ethics committee approval, serum NGAL was measured immediately after transplantation. Serum creatinine was measured immediately after transplantation and daily thereafter. The outcome variable was considered as AKI during the 1st week after transplantation. Slow graft function (SGF) was defined as serum creatinine reduction from transplantation to day 7 of <70% and immediate graft function (IGF) as reduction in serum creatinine ≤70% within the 1st week of transplantation. Results: The mean age of the patients was 33.3 ± 10.2 years (range: 17–57) with 80% males. SGF was observed in 16 patients (53.3%). The mean posttransplantation serum NGAL level was 716 ± 310 ng/ml in patients who had SGF whereas it was 318 ± 97 ng/ml in those with IGF (P ≤ 0.001). Receiver-operating characteristic curve showed that the area under the curve for NGAL in predicting SGF was 0.927 (P ≤ 0.001). The cutoff value for NGAL >363 ng/ml had a sensitivity of 91% and specificity of 77% in the prediction of SGF. Conclusion: Serum NGAL level seems to be an early accurate predictor of SGF within the 1st week of kidney transplantation.


  Manifestation of Bladder Dysfunction in Adult Renal-Transplant Recipients with No Pre-Existing Bladder or the Outlet Abnormality: A Critical Appraisal Top


Naveen Kumar, Yashpal Thakur, Sanjoy Sureka, U. P. Singh, M. S. Ansari, Rakesh Kapoor, Aneesh Srivastava

Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India. E-mail: naveen041988@gmail.com

Background: Up to 20% of renal-transplant recipients have anatomical or functional bladder or the outlet abnormalities which are either pre-existing or evident before the transplant or are latent and manifest during the posttransplant follow-up. This study focuses on overview, bladder management, and transplant outcome in patients with latent bladder or the outlet abnormalities, which manifested after the transplant in recipients. Aims of Study: To evaluate etiopathogenesis and manifestations of bladder dysfunction in adult renal-transplant recipients with no pre-existing bladder or the outlet abnormality. Methods: A prospective observational study of patients who underwent renal transplant with latent bladder abnormalities which manifested with a variable spectrum of lower urinary tract symptoms or the graft dysfunction was done from January 2011 to July 2016. We identified and noted the etiopathogenesis, posttransplant interventions required, bladder-related complications, and long-term graft function. Results: Of the 720 renal transplants performed, 160 patients (22.2%) had new-onset LUTS or latent bladder abnormalities which manifested within 1 month of renal transplant. The study cohort was divided in two groups: Group 1 (<6 months of nonsurgical treatment, n = 112) and Group 2 (>6 months of nonsurgical treatment and/or requiring surgical treatment, n = 48). The most common presenting symptom was dysuria (n = 110), increased frequency (n = 104), poor stream (n = 72), or both (n = 60). Etiologies included over active bladder (n = 76), transient voiding dysfunction (n = 52), primary bladder neck obstruction (n = 10), dysfunctional voiding (n = 4), diabetic cystopathy (n = 5), benign prostatic hypertrophy-related cystopathy (n = 8), and unidentified (n = 5). Group 1 was managed with short-term anticholinergics or alpha blockers or both and improved within 6 months. However, Group 2 was managed with continuous pharmacotherapy for > 6 months or clean intermittent catheterization and urotherapy (n = 39), bladder neck incision (n = 5), or TURP/TUIP (n = 4). Recurrent urinary tract infection (UTI) occurred in 15 (13%) versus 18 (38%) patients in Group 1 versus Group 2 (P = 0.01). Graft survival was comparable at 1 year between the groups (95% vs. 91%, P = 0.47). Conclusion: About 20% recipients manifest new-onset LUTS and are detected as either bladder dysfunction or outlet abnormalities in early posttransplant period. Those requiring long-term treatment are prone to frequent UTIs. Graft function was satisfactory following bladder management.


  Pediatric Kidney Donor with Weight Less Than 15 Kg as Donor for Adult Recipient: A Report of Two Cases Top


Gaurav Shanker Pandey, Abhinav Seth, Vidyasagar, Sarabpreet Singh, Deepesh B. Kenwar, Ashish Sharma

Department of Renal Transplant Surgery, PGIMER, Chandigarh, India. E-mail: gauravspandey91@gmail.com

Background: There has been an increase in organ donation in recent times which still could not meet the demand. Hence, there is need to increase the donor pool by accepting the marginal donor. Many studies suggest the feasibility of pediatric kidney transplant to an adult recipients, but no such literature has been published from India. We present two such case of pediatric donor weighing <15 kg operated at our center where kidney was transplanted to adult recipients with excellent graft function. Aims of Study: To report two cases of the pediatric kidney donor with weight <15 kg as donor for adult recipient. Methods: A 3-year-old female (weight 12 kg) was declared brain dead following a history of head trauma. Her kidneys were harvested and transplanted to two adult recipients, a 23-year-old female (weight 50 kg) and a 29-year-old male (weight 55 kg). Both recipients were induced with anti thymocyte globulin and were put on heparin infusion during postoperative period. Both male and female recipients have adequate urine output in postoperative period and were discharged with a creatinine of 2.6 and 1.2 mg/dl, respectively. At 6-month follow-up, their creatinine is 0.59 and 1.02 mg/dl, respectively. In another case, kidneys from an 11-month-old male (weight 8 kg) were transplanted to a 38-year-old female en bloc. She was induced with ATG and was kept on heparin infusion during postoperative period. She had uneventful postoperative course and was discharged with a creatinine of 0.8 mg/dl. Results: A 3-year old female (weight 12 kg) was declared brain dead following a history of head trauma. Her kidneys were harvested and transplanted to two adult recipients, a 23-year-old female (weight 50 kg) and a 29-year-old male (weight 55 kg). Both recipients were induced with ATG and were put on heparin infusion during postoperative period. Both male and female recipients had adequate urine output in postoperative period and were discharged with a creatinine of 2.6 and 1.2 mg/dl, respectively. At 6-month follow-up, their creatinine was 0.59 and 1.02 mg/dl, respectively. In another case, kidneys from an 11-month-old male (weight 8 kg) were transplanted to a 38-year-old female en bloc. She was induced with ATG and was kept on heparin infusion during postoperative period. She had uneventful postoperative course and was discharged with a creatinine of 0.8 mg/dl. Conclusion: Pediatric kidney can be used in suitable adult recipient to increase donor pool. Complications such as risk of thrombosis can be avoided by using meticulous surgical technique and anticoagulant therapy during postoperative period.


  Kidney Transplantation from Donation after Circulatory Death: A Novel Method to Increase Donor Pool Top


Gaurav Shanker Pandey, Abhinav Seth, Vidyasagar, Sarabpreet Singh, Deepesh B. Kenwar, Ashish Sharma

Department of Renal Transplant Surgery, PGIMER, Chandigarh, India. E-mail: gauravspandey91@gmail.com

Background: Donation after circulatory death (DCD) although a well-accepted source of organs worldwide is not practiced in India so far due to lack of proper guidelines for the same. The present report describes a single-center experience with DCD organs in India, its advantages, outcome, and associated challenges. Aims of Study: To report the evaluation of renal transplant outcome following DCD. Methods: During the 7-year period from February 2011 to February 2018, 126 deceased donors were harvested for renal transplant out of which 11 (8.73%) were DCD donors. Five had cardiac arrest after first brain death-certifying committee evaluation whereas two had cardiac arrest after brain death certification. Brain death certification was not given to two donors. One patient with terminal lung disease and one patient with head injury had cardiac arrest in intensive care unit. Donors received 25,000 units of heparin after being declared brain dead. Nine donors were started with chest compressions maintaining circulation and ventilation which was continued till the organs were retrieved. In the remaining two donors, cardio pulmonary resuscitation was discontinued before donor was shifted to operation theater. Rapid cannulation was done in all donors with infusion of cold preservative solution during organ retrieval surgery. All except one recipient received anti thymocyte globulin induction. All recipients received tacrolimus, mycophenolate, and steroids. Results: Twenty-two kidneys retrieved from 11 DCD donors out of which 19 (86.36%) were transplanted and three discarded (13.37%). One recipient underwent dual kidney transplant but graft nephrectomy was done in view of persistent intraoperative hypotension after declamping. Due to high resistance during perfusion, kidneys retrieved from one donor were discarded. Cause of death was head injury in all but one patient. Recipient's mean age was 40.58 ± 8.97 years with male-female ratio being 13:5. All recipients except two had graft dysfunction and required dialysis in postoperatively. Mean day 1 urine output was 2269.41 ml. The best baseline creatinine achieved was 1.35 ± 0.398 mg% after mean duration of 24 days. The kidneys from donors where CPR was performed after death fared better with early recovery and less time to achieve normal renal function. Conclusion: DCD donation presents as a viable option to increase the donor pool in deceased donor program, especially with already constraint organ supply for a large population of patient awaiting transplant. CPR seems to help improve the outcome following circulatory death in a DCD donor.


  Real-World Clinical Bioequivalence of Tacrolimus in Patients with Live-Related Donor De novo Renal Transplantation: An Observational Study Top


Priyanka Naithani, Ashish Sharma1, Deepesh B. Kenwar1, Sarabpreet Singh1, Savita Verma Attri2, Smita Pattanaik

Department of Pharmacology, 1Renal Transplant Surgery and 2Pediatrics, PGIMER, Chandigarh, India. E-mail: drs_pattanaik@yahoo.com

Background: Tacrolimus is an indispensable drug in the combined immunosuppressive regimen for maintenance of kidney graft survival. Optimal use of this drug is challenging for the physician because of its narrow therapeutic index. Optimization of drug dosage become more important in cases where the branded/generic branded was substituted with the generic preparations of tacrolimus. In these cases, a fine tuning of the drug dosage for a target exposure is mandatory for best graft outcome. Aims of Study: To compare the whole blood tacrolimus concentration before and after switching to generic tacrolimus in patients with live-related donor de novo renal transplantation. Methods: This is a prospective observational study, including the participants who underwent renal transplantation at PGIMER. There was no intervention (pharmacologic or surgical) for the purpose of the study. The recipients of the live-related donor transplant who have undergone surgery at least 1 month prior were screened. Those who are being planned for switch from one brand of tacrolimus (Group-I: branded, generic) to another (Group-II: generic) were requested to participate in the study. The substitution dose of the generic was the same as that of a dose of previous branded or generic tacrolimus on which the participant maintained a C0 concentration within the therapeutic range. After substitution, the C0 was performed again at least after 3 days (minimum of 6 doses of generic administration) or 3 ± 1 days as per the patient convenience. The trough (C0) concentration of tacrolimus in whole blood was determined by using the LC-MS technique. Results: Twenty-one patients were recruited in a prospective manner. Mean age was 34 ± 12.1, and 90% were male. After comparing the C0 levels between Group-I (median interquartile range [IQR] = 10.0 [7.5–14.4]) and Group-II (median IQR = 9.0 [7.0–11.0]), we did not find any significant difference (P = 0.248). Conclusion: Patient recruitment in the study is in continuation to compare tacrolimus trough (C0) concentration between the branded/branded generic and generic preparations in patients with live-related donor de novo renal transplantation.


  Acute Kidney Injury after Liver Transplant: Risk Factors and Clinical Outcome Top


Hitesh Gulhane, Zaheer Amin Virani, Prashant Rajput, Vaishali Salao, Pawan Deore, Hepal Vora, Ishan Parekh, Menal Wali, Neel Saldana, Mita Shah, Bharat Shah

Global Hospital, Opposite Shirodkar High School, Parel, Mumbai, Maharashtra, India. E-mail: drhiteshgulhane@gmail.com

Background: Acute kidney injury (AKI) is the most common complication in patients undergoing liver transplant. Postliver transplant AKI imparts adverse effect on graft outcome and patient recovery. Aims of Study: To assess risk factors, clinical profile, and outcome of AKI after liver transplant (LT). Methods: This is a retrospective study, which included all post-LT patients between March 2015 and January 2018. Patients with pretransplant AKI were excluded. Patients were divided into two groups, Group I with AKI (as per KDIGO definition) and Group II without AKI. Demographic profile, presentation of liver failure, comorbidities, complications, graft dysfunction, hospital stay, and perioperative and 30-day mortality were compared. Results: Of 174 studied patients, 76 developed AKI. Hypertensive patients were at more risk of developing AKI (P = 0.014). Acute liver failure (ALF) (7 out of 32) and acute on chronic liver failure (ACLF) (10 out of 14) as etiology of liver failure are risk factors for developing AKI (P = 0.005) as compared to CLD (59 out of 128). Sepsis and need for blood and blood products were associated with post-transplant AKI (P < 0.05). Other contributing factors for AKI were intraoperative hypotension, need of ≤2 vasopressors, baseline diabetes mellitus, prolonged operative time (≤8 h), graft dysfunction, biopsy-proven acute cell mediated rejection (P > 0.05). Patients with AKI had prolonged intensive care unit (ICU), hospital stay (P > 0.05), and increased perioperative and 30-day mortality as compared to non-AKI group (5.2% and 6.5% vs. 2% and 4%). Conclusion: AKI is an important complication after LT. This risk is substantially high in those who had ALF or ACLF, sepsis, need of more blood products, intraoperative hypotension, and prolonged surgery. Development of AKI leads to increased mortality, ICU, and hospital stay.


  Nodular Cutaneous Swellings in Solid Organ Transplantation: Case Series Top


Manisha Gupta, T. N. Dhole, R. S. K. Marak

SGPGI, Lucknow, Uttar Pradesh, India. E-mail: dreamsmaterialise@gmail.com

Background: Phaeohyphomycosis is a heterogeneous group of opportunistic infections caused by dematiaceous molds, which are ubiquitous, but rarely cause human disease. However, due to the growing populations of immunocompromised patients, including solid organ transplant recipients, these fungi are increasingly recognized as important human pathogens. Aims of Study: We communicate four cases of cutaneous phaeohyphomycosis with an aim to highlight diverse clinical characteristics, varied severity, evolution, and impediments for successful outcome. Methods: A 36-year-old man post-renal transplant (RT) presented with a 1-month history of cutaneous nodule on dorsum of foot and right forearm. Histopathology revealed pigmented mycelium. Culture yielded curvularia lunata. The patient was treated with itraconazole. A 35-year-old male post-RT presented with a 7 cm × 6 cm swelling on the right thigh. Histopathology showed pigmented fungal hyphae and culture grew phaeoid fungi. Management included surgical excision and prolonged course of itraconazole. The patient has recurrent relapses and is on follow-up. A 59-year-old female who underwent RT in 2012 on MMF was referred for a right pretibial swelling. Culture confirmed phaeohyphomycosis, pretibial swelling decreased on itraconazole. A 33-year-old male who underwent RT in 2013 for chronic glomerulonephritis on mycophenolate mofetel presented with fluctuant cyst 23 mm × 15 mm was found on medial side of left knee. Skin biopsy revealed pigmented hyphae. Culture yielded a dematiaceous fungus. The patient was managed with itraconazole however took leave against medical advice and was lost to follow-up. Results: Phaeohyphomycoses are rare opportunistic fungal infections; more than 100 different species of dematiaceous molds have been attributed. Surgery and medical treatment are advocated to avoid local dissemination. Triazoles are currently the drugs of choice, often combined with other agents. One of the major points to consider using broad-spectrum azoles in allograft recipients is major drug–drug interactions with several immunosuppressive agents. The diagnosis of phaeohyphomycosis, as noted in our study, primarily relied on culture. Histopathological examination of tissue specimens is limited by inability to delineate species-level identification. Conclusion: Phaeohyphomycosis is an increasingly recognized infection. Culture remains the most frequently used diagnostic method. Itraconazole exhibits good clinical efficacy against a large spectrum of black molds and have been found to have a low impact on graft function and mortality.


  Preoperative Blood Transfusion Is Strong Determinant of Postoperative Graft Outcome in Renal Transplant: Role of Single Antigen Bead Assay Top


Rakesh Chauhan, Ashish Sharma, Deepesh B. Kenwar, Sarbpreet Singh, Kunal, Sahil Rally

Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drrakeshchauhan66@gmail.com

Background: Blood transfusion has a strong potential to induce sensitization. Chronic kidney disease patients with end-stage renal disease (ESRD) are at a risk of anemia and need some measures to treat it. In the present era when other options such as erythropoietin analogs are available, blood transfusion should be avoided as it exposes the patients to allosensitization leading to graft rejection and loss or long waiting time in the list. Aims of Study: To study the effect of pretransplant blood transfusion on renal graft outcome. Methods: The authors have conducted a study in PGIMER, Chandigarh, in 46 patients between March 2018 and July 2018. ESRD patients on dialysis with the history of transfusion, who were potential candidates for transplantation, were worked up in the preoperative transplant outpatient department and were included in the study. Mean blood transfusion was 2.7 units/patient. Those with history of previous transplantation or pregnancy were excluded from the study. Selected patients were cross-matched with their live donors with center for disease control, Flow cross match, and single antigen bead assay (SAB). Any MFI >1000 on SAB with Luminex method was taken as positive result as a predictor of sensitization. The patients were tested against HLA-A, HLA-B, and HLA-DR loci. The patients underwent transplantation with standard immunosuppression with anti thymocyte globulin induction if donor-specific antibody (DSA) was present, tacrolimus, mycophenolate, and prednisolone. Postoperative graft biopsy was done if any time creatinine value increased by 15% on two respective occasions. Results: Out of 46 patients included in the study, 36 were males and 10 were females with mean age of 33.7 years. Thiry-seven of the donors were females in different relations, mothers being highest in number. Nine donors were males. 23 (50%) patients were of B blood group, 10 (21%) of AB, 9 (19%) of A, and 4 (8%) of O group. 19 (41%) patients were pretransplant SAB positive. Out of these 19 patients, seven had antibodies against the HLA of the respective donors and 12 had antibodies against nondonor HLA. There was rejection in 8 (17%) patients with positive SAB which is 42.1% of the SAB-positive cases. However, in patients with negative SAB, only 2 (7.4%) had acute rejection. The mean creatinine of DSA-positive patients was 1.3 and 1.27 mg% at discharge and follow-up, whereas creatinine of DSA negative patients was 1.2 mg% and 1.05 mg% at discharge and 6-month follow-up, respectively. The mean creatinine of the DSA-positive patients who had rejection was 1.5 and 1.2 mg% at discharge and at follow-up. Conclusion: This study proves that blood transfusion strongly exposes the kidney transplant patients to the allosensitization and rejection. Intensification of immunosuppression with avoidance of blood transfusion may improve the graft outcome.


  A Study to Evaluate the Short-Term Impact of Donor Kidney Weight and Glomerular Filtration Rate on Renal Graft Function Top


Yogesh, D. S. Rana, Ashwani Gupta, Manish Malik, Nayanesh

Sir Ganga Ram Hospital, New Delhi, India. E-mail: c_nayanesh@rediffmail.com

Background: The effect of nephron reduction has long been described in animal models as well as in humans. Aims of Study: To study the short-term impact of the donor kidney weight (DKW) and glomerular filtration rate (GFR) on recipient graft function in live donor kidney-transplant patients. Methods: It was a prospective study of 70 live donor kidney-transplant recipients. To compare the effect of DKW on recipient graft function, patients were divided into four groups depending on the DKW in grams, corrected for body surface area of respective recipient. To assess the effect of GFR of donor on recipient graft function, patients were divided into two groups depending on GFR of donor. Serum creatinine in milligrams percent on the 7th day, 1st month, 3rd month, and 6th month was recorded and their means were compared. Results: The comparison showed that the decrease in mean creatinine level was more in group with higher DKW and higher GFR as compared to groups with lower DKW and lower GFR at 7 days, 1 month, and 3 months, showing that higher DKW and higher GFR are beneficial with respect to the early graft function. However, this decrease was not statistically significant at 6th month. Conclusion: For short-term period after posttransplantation (till 3 months), higher weight and higher GFR of donor kidney have better recipient graft function in comparison to lower weight and lower GFR of donor kidney.


  Laparoscopic Repair of Postkidney-Transplant Incisional Hernia: A Case Report Top


Om Prakash, Subodh Kumar1, A. Krishna1, Umar Maqbool1, V. K Bansal1

Departments of Renal Transplant and 1Surgical Disciplines, AIIMS, New Delhi, India. E-mail: umar777in@gmail.com

Background: Transplant patients are at increased risk for hernia formation due to impaired normal wound-healing process. This is partly attributed to postoperative immunosuppressive therapy. After kidney transplantation, the incisional hernia formation ranges from 1.6%–18% and most of the cases present within the first 5 years posttransplant. Laparoscopic surgery is associated with reduced tissue trauma and lower risk for postoperative complications. Aims of Study: NA. Methods: A 39-year-old patient underwent live renal transplant, which was uneventful. On postoperative day (POD) 4, he developed abdominal distension and his bowel sounds were exaggerated. Nasogastric tube was inserted and the patient was kept nothing per orally and put on intravenous fluids. His electrolytes were normal. On passage of flatus, he was started on sips of water after 2 days and gradually given semisolid diet. However, he continued to have constipation. He developed recurrent episodes of sub acute intestinal obstruction. X-ray abdomen showed mild dilatation of small bowel loops but no air-fluid levels. The patient continued to have constipation and recurrent subacute obstruction. On POD 26, he developed severe pain in abdomen with abdominal distension and obstipation. On insertion of nasogastric tube, 500 mL of bilious output was noted. Bowel sounds were exaggerated and X-ray abdomen showed dilated bowel loops. Results: Emergency diagnostic laparoscopy was performed. A 5-mm telescope was inserted above the umbilicus, which showed an internal hernia just above the graft kidney. A 2 cm × 2 cm peritoneal defect was noted, with ileal loop as content. The ileal loop was reduced; however, there was an inadvertent serosal tear in the ileal loop, which was repaired by intracorporeal suturing with 3-0 Vicryl. The peritoneal defect was closed with a 3-0 V-loc suture. Postoperative period was uneventful and the patient was discharged on POD 10. Conclusion: Incisional hernias have a minor impact on patient and graft survival. It has an adverse impact on patients' quality of life. Postoperative complications are minimized with laparoscopic hernia repair. Hernias can be safely repaired with minimally invasive techniques in posttransplant patients.


  Initial Experience of Simultaneous Cadaver Pancreas and Live Donor Kidney Transplantation: Pilot Study Top


Senthil Muthuraman, Anil Vaidhya Mohammed, Nayeem Karthick, Mathivanan Dinesh Babu

Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India. E-mail: drsenthilm@gmail.com

Background: simultaneous pancreas transplant provide an advantage of good glycemic control result in prolonged survival of the renal graft which would otherwise get affect by diabetes once again. Added advantage of pancreas transplant is on a long run good glycemic control which is able to reverse the microvascular and macrovascular changes. Aims of Study: To study the feasibility of simultaneous cadaver pancreas and live donor kidney transplant in Indian scenario where the organ allocation system does not priorities end-stage renal failure (ESRD) patient due to diabetes mellitus (DM). Methods: A series three patients suffering from ESRD due to insulin-dependent DM who are on regular dialysis where registered for simultaneous pancreas–kidney transplantation. Our state has the better organ donation rate in the country, but waiting period for a cadaver renal transplant is minimum 4–5 years. However, these patients the mortality increases on waiting list. With a live donor kidney option in the family and where no taker for pancreas, we proceed with the option of simultaneous cadaver pancreas and live donor kidney transplant. Results: The male:Fem ratio 1:2. They all underwent simultaneous cadaver pancreas and live donor kidney transplant after routine pre-transplant evaluation. After assessment of cadaver pancreas, they are harvested and back benching done by standard technique. They underwent pancreas implantation with entering drainage in right paramedian position with kidney implantation on the left iliac fossa. Postoperatively, they were kept nothing by mouth and maintained on 25% dextrose for 36-48 h and on average they were started on orals liquid diet on the postoperative day (POD) 2. Both female patients had postoperative ileus managed conservatively and orals restarted on POD 4. Immunosuppressions are managed according to our institution protocol. On average, all three patients were discharged by POD 7. Their post-operative course does not significantly differ from postoperative course of cadaver simultaneous pancreas-kidney transplant. Conclusion: Simultaneous cadaver pancreas and live donor kidney seem to be promising option for all these ESRD patients due to DM where we are able to provide the benefit of pancreas transplant even though allocation system is a rate-limiting step for a pancreas transplant program in India.


  To Compare the Clinical Outcome of Induction Prophylaxis in Renal Transplant Patients with Single Dose of 1.5 mg/kg Antithymocyte Globulin with Three Doses of 1 mg/kg/day Antithymocyte Globulin Top


Abhinav Seth, Ashish Sharma, Sarbpreet Singh, Gaurav Shankar Pandey, Vidyasagar Kallepalli

Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drabhinavseth@gmail.com

Background: Antithymocyte globulin (ATG) is an infusion of horse or rabbit-derived antibodies which causes a significant depletion of CD3+, CD4+, CD8+, and natural killer cells, leading to lower incidence of acute rejection. However, this is counterbalanced by increase in serious infections. Currently, induction prophylaxis with 3–7 mg/kg/day ATG is the recommended dose. However, many Indian centers use a single dose (1–1.5 mg/kg) because of fear of life-threatening infections. The efficacy of this dose has never been studied. Aims of Study: To evaluate whether a low-dose ATG regime of 1.5 mg/kg is as efficacious as the standard regimen of 3 mg/kg in terms of occurrence of graft dysfunction and infections. Methods: This was a prospective randomized study in patients of renal transplant, divided into two groups: Group I: Induction prophylaxis with a single dose of 1.5 mg/kg ATG on day 0; Group II: Induction prophylaxis with 3 doses of 1 mg/kg/day ATG on day 0, 1, and 2. Patients with age >18 years undergoing, living donor transplant with >3/6, HLA mismatch or deceased donor transplant were included. All patients underwent triple drug immunosuppression with tacrolimus, mycophenolate, and prednisolone. Patients underwent protocol biopsy at 1 and 3 months posttransplantation and when clinically indicated. The outcome was studied in terms of incidence of acute rejection, incidence of various infections, CD3+ counts, incidence of delayed graft function, biopsy findings, and graft dysfunction between the two groups over a period of 6 months. Results: There were 21 patients in Group 1 and 25 patients in Group 2 with a mean age of 39.10 ± 8.71 and 41.48 ± 8.94 years, respectively. There was predominance of males in both groups (male:female-13:8 in Group I and 18:7 in Group II). 12/21 patients in Group I and 10/25 patients in Group II received a deceased donor kidney. The cause of end-stage renal disease was unknown in majority of patients in both groups (76.19% and 72%, respectively). The mean creatinine values for Group I and Group II at 1 month were 1.26 ± 0.53 mg% and 1.33 ± 0.37 mg%, respectively, and at 6 months were 1.21 ± 0.41 mg% and 1.20 ± 0.26 mg%, respectively. Biopsy-proven acute rejection was seen in 5 (23%) patients in Group I versus 4 (16%) patients in Group II. Serious life-threatening infection was seen in two patients in Group I and in one patient in Group II. There was one death in Group I. The absolute CD3+ count in Group I measured on the next day of ATG dose was 510. The CD3+ count in Group II measured on the next day of last dose of ATG was 471. Conclusion: Three doses of ATG (1 mg/kg/day) result in a lesser incidence of acute rejection as compared to a single dose ATG (1.5 mg/kg) in preventing rejection with no increase in infectious complications.


  Living Donor Renal Transplantation without Any Induction Immunosuppression in Spousal Donors: Our Experience Top


Raghuramachandra Bhat, Sajith Narayanan, N. A. Ismail, Feroz Aziz, Benil Hafeeq

Aster MIMS Hospital, Calicut, Kerala, India. E-mail: raghurambhat.r@gmail.com

Background: Renal transplantation in India is primarily driven by living-related donation; parents and spouse constitute 70% of donors in India. Some centers use induction immune suppression (IIS) for all spousal transplants considering it as an immunologically high-risk scenario. Our protocol is to give induction only if recipients are of immunologically high risk from anti-HLA antibody perspective. Aims of Study: To compare the incidence of rejection in the 1st posttransplant year, graft loss, and patient loss among patients who underwent renal transplantation from parental donor and spousal donor without IIS. Methods: It is single-center-based, a retrospective study of living donor renal transplantation of parents and spouse (wife) as donors. Patients from January 2006 to December 2016 were included. We excluded patients with induction therapy and ABOi transplantation and female recipients with husband donors who had pregnancy as sensitizing event, and patients with lost or irregular follow-ups. Patients' baseline characteristics, rejection by 1-year post-transplantation, graft loss, and patient loss were analyzed. Results: Of 361 patients, 154 belonged to parental donor and 75 patients to spousal donor groups with an average follow-up of 2009 ± 998 and 1740 ± 922 days, respectively. The mean age of recipients was significantly lower in parent group (27.8 ± 6.9 years) than in spouse group (45.6 ± 7.9 years). Donor age was much higher in parent group (50.4 ± 7.3 years) than the spouse group (38.4 ± 7.8 years). Spouse group received kidney with mean glomerular filtration rate (GFR) of 49 ± 43.3 ml/min which was significantly higher than the parent donor group 38.9 ± 9.3 ml/min (P = 0.02). The incidence of acute rejections in the 1st posttransplant year was comparable with 18% and 17% in parent-donor and spouse-donor groups, respectively. Parental donor had more antibody mediated rejection and mixed rejections; acute cell mediated rejection rejections were more common in spouse donors. Patient loss and death-censored graft loss were comparable in both groups. Five-year patient survival was 95% and 92%, 5-year death-censored graft survival was 87% and 91% in parental-donor and spousal-donor groups, respectively. Conclusion: Spousal kidney donation can provide more age compatible transplantation with better GFR without augmented IIS in patients with low immunological risk, leading to better long-term graft and patient survival when compared to traditionally considered low-immunological risk parental kidney donation.


  A Novel Technique of Dual Kidney Transplantation Top


Abhinav Seth, Ashish Sharma, Deepesh Benjamine Kenwar, Vidyasagar Kallepalli, Gaurav Shankar Pandey

Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drabhinavseth@gmail.com

Background: Dual kidney transplantation (DKT) is done for expanded criteria kidneys. The three described techniques in literature (bilateral placement, unilateral placement with separate or patch anastomosis) have some disadvantages. Bilateral placement leads to both sides being scarred, leading to exhaustion of both iliac fossa for a future transplant. Unilateral placement with separate anastomosis takes longer operative time and anastomizing both kidneys on a patch makes the surgery technically more challenging with the constraint of space. Aims of Study: To predict factors for intraoperative surgical difficulty in renal-transplant recipients. Methods: This was a prospective observational study involving 75 recipients who underwent open iliac fossa renal transplantation at a high-volume transplant center in northern India between June 2017 and May 2018. Demographic profile of the recipients and anthropometric measurements (abdominal girth, skin to vessel distance, anteroposterior distance, umbilicus to pubis, and umbilicus to anterior superior ileac spine) were taken preoperatively and intraoperatively. Intraoperative surgical difficulty for anastomosis was measured on a Likert scale ranging from 1 to 10 by the surgical team, where 1 was the least and 10 was the maximum possible surgical difficulty. The difficulty levels were further classified into three groups – mild, moderate, and severe. Results: The mean total anastomotic time was 74.72 ± 30.7 min. The mean venous, arterial, and ureterovesical anastomosis times were 19.4 ± 7.6 (10–40), 39.1 ± 21.9 (10–100), and 16.6 ± 7.11 (5–40) min, respectively. Longer duration with chronic kidney disease (CKD) (P = 0.007, Spearman Ï = 0.309), age (P = 0.017, Spearman Ï = 0.274) and skin to vessels distance (P = 0.00) were associated with increased difficulty in anastomosis with skin to vein distance (Spearman Ï = 0.501) having the highest correlation. Increased intraoperative difficulty also correlated with slow graft function (P = 0.002), but the discharge and trough serum creatinine were unaffected. Conclusion: Variables such as increased age, longer duration with CKD and on dialysis, and greater skin to vessels distance predicted increased intraoperative difficulty also translating to slow graft function. These factors can be used to preempt a possible difficult surgery to avoid possible complications.


  Predictors of Intraoperative Surgical Difficulty in Renal-Transplant Recipients: A Prospective Observational Study Top


Naveen Kumar, Anil Mani, Rakesh Kapoor, Uday Pratap Singh, M. S. Ansari, Sanjoy Sureka, Aneesh Srivastava

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: anees@sgpgi.ac.in and naveen041988@gmail.com

Background: Renal transplantation surgery can become challenging in some special situations. The objective of this study was to assess the factors, which predicted increased intraoperative difficulty in renal-transplant recipients and evaluate the correlation between those factors. Aims of Study: To predict factors for intraoperative surgical difficulty in renal-transplant recipients. Methods: This was a prospective observational study involving 75 recipients who underwent open iliac fossa renal transplantation at a high-volume transplant center in Northern India between June 2017 and May 2018. Demographic profile of the recipients and anthropometric measurements (abdominal girth, skin to vessel distance, anteroposterior distance, umbilicus to pubis, and umbilicus to ASIS) were taken preoperatively and intraoperatively. Intraoperative surgical difficulty for anastomosis was measured on a Likert scale ranging from 1 to 10 by the surgical team, where 1 was the least and 10 was the maximum possible surgical difficulty. The difficulty levels were further classified into three groups – mild, moderate, and severe. Results: The mean total anastomotic time was 74.72 ± 30.7 min. The mean venous, arterial, and ureterovesical anastomosis times were 19.4 ± 7.6 (10–40), 39.1 ± 21.9 (10–100), and 16.6 ± 7.11 (5–40) min, respectively. Longer duration with chronic kidney disease (CKD) (P = 0.007, Spearman Ï = 0.309), age (P = 0.017, spearman Ï = 0.274), and skin to vessel distance (P = 0.00) were associated with increased difficulty in anastomosis with skin to vein distance (spearman Ï = 0.501) having the highest correlation. Increased intraoperative difficulty also correlated with slow graft function (P = 0.002) but the discharge and trough serum creatinine were unaffected. Conclusion: Variables such as increased age, longer duration with CKD and on dialysis, and greater skin to vessels distance predicted increased intraoperative difficulty also translating to slow graft function. These factors can be used to preempt a possible difficult surgery to avoid possible complications.


  Comparison of Induction versus Noninduction on Graft Outcome and Infection Rate in Live-Related Renal-Transplant Recipients Top


Irfan Ahmad, Sanjiv Saxena, Ravi Bansal, Rajesh Goel

PSRI Hospital and Research Institute, New Delhi, India. E-mail: drirfan24@gmail.com

Background: With increasing number of renal transplantation and fear of rejection, induction therapy has become routine. However, a large number of recipients have haploidentical or good-matched donors. Infections are major cause of morbidity and mortality in our patients. Hence, it is important to find out the role of induction and noninduction therapy on outcome and infection rate in our transplant recipients. Aims of Study: Comparison of induction versus noninduction on graft outcome and infection rate in live-related renal-transplant recipients. Methods: All patients who underwent live-related renal-transplant from January 1, 2010, to March 30, 2016, in our center were included after applying inclusion and exclusion criteria. In this retrospective observational study, all data and laboratory reports were collected from medical records and outpatient department visit records from time of transplant until 24-month posttransplant. Clinically suspected (treated) or biopsy-proven rejection, serum creatinine at 1, 6, 12, and 24 months after transplant, treatment response and efficacy of antirejection drugs, clinically significant infection, and hospitalization were recorded. Statistical analysis was performed using SPSS software. Results: A total of 200 patients were included, of which 100 in noninduction and 100 in induction group. Incidence of acute graft rejection at 3 months was 9% overall, 13% in noninduction, and 5% in induction group, which was statistically significant (P = 0.048). Incidence of late graft rejection was 8% overall, 10% in noninduction, and 6% in induction group, which was statistically not significant. Difference in serum creatinine was significant at 1 month only (P = 0.01). Urinary tract infection was the most common infection occurred in 20.5%, 17% in noninduction and 24% in induction group (P = 0.220). Respiratory infection occurred in 9.5%, 8% in noninduction, and 11% in induction group. Incidence of CMV infection was 3% in noninduction and 6% in induction group (P = 0.498). BKV occurred in 1% in noninduction and 2% in induction group. Hence, the incidence of infection was higher in induction group, but they were statistically not significant. Graft outcome at 2 years was comparable between two groups. Infection was the cause of death in all mortality. Conclusion: In long-term induction, therapy may not have major effect on graft outcome. It is responsible for infections which are common cause of morbidity and mortality. Hence, they should be used carefully.


  Biopsy-Proven Graft Pyelonephritis: A Series of 10 Cases Top


Dhanin Puthiyottil, Sreejith Parameswaran, P. S. Priyamvada, V. Arjun Pradeep, H. Satish

Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India. E-mail: dhanin48@gmail.com

Background: The prevalence of graft pyelonephritis in renal transplant recipients is 10%–17% and whether it impacts graft outcome has remained contentious. Aims of Study: To study the incidence of biopsy-proven graft pyelonephritis, its clinical characteristics, and outcome. Methods: Retrospective data regarding biopsy-proven graft pyelonephritis were obtained from the hospital records of patients who underwent renal transplantation between 2012 and 2018. The clinical features risk factors and graft outcomes were assessed in these patients. Results: A total of 160 patients underwent transplant during this time period. Ten patients (6.25%) were diagnosed with 15 episodes of biopsy-proven graft pyelonephritis (6 males and 4 females), six had post transplant diabetes mellitus, and five had immediate posttransplant urinary tract infection. Pyelonephritis occurred from 24 days to 45 months posttransplant, with an average fall in glomerular filtration rate (GFR) of 47.3% (21.2%–85.7%) during the episode. While 7/10 had fever, only 5/10 had leukocytosis. Organisms ( Escherichia More Details coli, Enterobacter, and Pseudomonas) were isolated in eight cases, while two cases were culture negative. Rejection therapy was followed by pyelonephritis within 1 week, 3 months, and 5 months in three patients, respectively. After complete cure of pyelonephritis, at 6 months postincidence, six patients had improvement in GFR (4 – 46.5 mL/min) and graft function returned to baseline in only 3/10 patients. Decrease in final graft function was seen in four patients who had recurrence of pyelonephritis, associated antibody-mediated rejection, or significant glomerular sclerosis. Conclusion: Acute graft pyelonephritis is associated with significant reduction in graft function when there is another concurrent insult like rejection or chronic allograft injury.


  Dengue in Renal Allograft Transplant Recipients and the Effect of Dengue Screening in Both Donor and Recipient and Its Outcome after Transplant Top


Vidyasagar Kallepalli, Deepesh

PGIMER, Chandigarh, India. E-mail: vidyasagar1217@gmail.com

Background: India is an endemic zone for dengue which is caused by an Arbovirus transmitted by the mosquitoes Aedes aegypti. Renal-transplant recipients who live or travel in endemic zones of dengue are at risk of contracting this infection. A few case reports have described dengue infection in renal-transplant recipients with the transmission of dengue from donor to recipient, but no study in literature described the effect of dengue screening of both donor and recipient before undergoing transplant. Aims of Study: To study dengue infection in renal allograft transplant recipients and to describe the results of pretransplant dengue screening in both donor and recipient. Methods: Between June 2107 and November 2017, renal-transplant recipients with dengue were identified based on either NS-1 or IgM positivity with typical clinical syndrome of fever, myalgia, arthralgia, headache, facial flushing, leucopenia, thrombocytopenia, and transaminitis. Baseline hemogram and renal and liver function tests were done and subsequently followed up. Mycophenolate (MMF) was withheld or reduced when leukocytes <4000 or platelet count <50,000. Platelet transfusions were given when platelets were <10,000 or bleeding manifested. MMF was restarted once the platelets were >75,000 or were showing steady improving trend. Granulocyte colony-stimulating factor was given to the patients with absolute neutrophil count <1000. Screening for dengue was initiated in both donor and recipient before transplantation after the first case of dengue infection was detected in the perioperative period. These patients were followed up and evaluated for dengue if postoperative fever occurred. Results: Renal allograft recipients with dengue infection were 36 (male:female = 31:5) with mean age of 37.13 years and mean transplant duration of 36.2 months. NS-1 was positive in 35 whereas dengue IgM was positive in 19 patients. Fever was present in all patients, myalgia 18, arthralgia in 12, vomiting in 10, headache in 7, diarrhea in 9, leucopenia in 24, and thrombocytopenia in 34 cases. MMF stopped in 29 and reduced to half in 3 cases. Creatinine raise (>25% from baseline) in 21 patients of whom 16 were achieved their baseline whereas three were not. There were two mortalities with dengue shock syndrome, three cases of dengue ophthalmopathy, and one case of dengue encephalopathy. Two patients received G-CSF and 2 received single-donor platelets. Out of 44 donor-recipient pairs screened for dengue using NS-1 antigen and IgM antibody, eight were positive. After a mean waiting period of 7.16 weeks, NS-1 was negative in all pairs in which one recipient developed and recovered from dengue during postoperative period. Conclusion: Renal allograft recipients with dengue will have reversible graft dysfunction and should have a high index of suspicion for complications in the early posttransplant period. Screening of donor and recipient for dengue should be done before transplant in endemic areas during the dengue season.


  A Retrospective Study of Acute Rejections in ABO-Compatible Living Donor Renal Transplant: Clinical Profile and Implications for 5-Year Allograft Function in a Tertiary Center in South India Top


Arvind Krishnakumar, Vinoi G. David, Suceena Alexander, Shibu Jacob, Anjali Mohapatra, Anna Valson, Pradeep M. Koshy, Gautam Rajan, Santosh Varughese

Christian Medical College, Vellore, Tamil Nadu, India. E-mail: arvind. krishnakumar87@gmail.com

Background: Although the incidence of acute rejection has reduced from 17% to 8% over the last decade, episodes of rejection still have an impact on long-term graft survival. However, long-term renal graft function after therapy for acute rejection has not been established. This study compares clinical profile of acute rejections in renal-transplant recipients and graft function after 5 years of an episode of rejection, with patients who have not had rejection. Aims of Study: To compare estimated glomerular filtration rate (eGFR) at 5 years in patients postrejection, with that in patients who did not have rejection. To assess clinical profile and determine risk factors in patients who developed rejection. Methods: This study is a retrospective analysis of patients who suffered from at least one episode of acute rejection after a living donor renal transplant that occurred between January 1, 2008, and December 31, 2012, in Christian Medical College, Vellore. eGFR was calculated using the CKD-EPI formula. Histopathological findings were scored according to the latest Banff criteria for rejection. The clinical profile included factors that are enlisted in the pro forma attached was collected in a pro forma. These patients were compared with age- and sex-matched transplant patients of the same period, who did not have any episode of rejection. Data were collected as per the pro forma and subjected to statistical analysis. Results: A total of 320 blood group compatible live-related donor transplants were performed between the above-said period, of which 40.62% (n = 130) suffered from an episode of acute rejection. Forty patients had acute cellular rejection (30.77%) and 45 (34.6%) had acute antibody-mediated rejection. Thirty patients fit into the criteria of borderline rejection (23.07%) and 10 (7.7%) had mixed rejection. The eGFR at 5 years after an episode of rejection was best for patients diagnosed with acute cellular rejection (median eGFR 65.58 ml/min/1.73 m2), although not clinically significant (P = 0.45) when compared to those diagnosed with acute antibody-mediated rejection (64.99 ml/min/1.73 m2). Compared to control group, the median eGFR of study group at 5 years was similar (65.03 vs. 67 ml/min/1.73 m2). The incidence of opportunistic infections was also comparable between the study and control groups. Among the risk factors, prolonged cold ischemia time correlated the best with incidence of rejection. Conclusion: Five-year allograft function in patients who suffered a single episode of rejection, if treated adequately, remains comparable to those who did not experience rejection at all. Prolonged cold ischemia time is the most important risk factor incidence of rejection.


  Our Experience with Pediatric Renal Transplantation Top


A. K. Mohammed Shoeb, K. Vinod Kumar, K. P. Jojo, P. K. Bipi, T. A. Kishore, V. N. Unni

Aster Medcity, Kochi, Kerala, India. E-mail: drshoeb1988@gmail.com

Background: Prevalence of end-stage renal disease in children is not known in India due to lack of active national registry. Transplantation offers the best survival in children and also gives an edge over dialysis in nutrition, cognition, and growth. Kidney transplantation in children is challenged by various urological issues and increased vascular complications. We present our experience of renal transplantation in children predominately with congenital anomalies of kidney and urinary tract. Aims of Study: To study our experience with kidney transplantation in children at Aster Medcity. Methods: A retrospective study of all pediatric renal transplantations (up to the age of 18 years) was done at Aster Medcity, Kochi, from January 2016 to July 2018. There were 17 recipients (11 males and 6 females). Clinical data, outcome, and complications were analyzed. Results: The mean age was 11.6 ± 5 years (1 year 8 months to 18 years). There were two infants aged below 2 years and eight children between 3 and 12 years. The mean duration of follow-up was 12 ± 5.7 months. Most common causes of renal disease leading to transplantation were congenital malformations of the kidneys and urinary tract (49.8%), followed by chronic glomerulonephritis (21.4%). Open renal transplantation surgery done in 14 patients and three underwent robot-assisted surgery. There were 16 live-related donors and one deceased donor (Mean age of donor was 43 ± 11.3 years). One infant with primary hyperoxaluria underwent a combined liver and kidney transplantation. The recipients were given triple immunosuppression with tacrolimus (0.1 mg/kg/day), mycophenolate mofetil (35 mg/kg/day), and prednisolone (0.5 mg/kg/day). Seven children were given basiliximab (2 doses) as induction therapy and thymoglobulin was given for one (a case of second transplant). Biopsy-proven acute graft rejection was seen in two patients (11%), all responded to treatment with steroids, and tacrolimus toxicity was seen in one patient. The most common medical complication was urinary tract infection which occurred in the first 3 months after transplant. There were eight episodes of urinary tract infection (3 patients), one child developed molluscum contagiosum, and one developed staphylococcal gluteal abscess with bacteremia. No one developed new-onset diabetes mellitus after transplant or erythrocytosis. There were no surgical complications such as urine leak, lymphocele, graft thrombosis, or hemorrhage. The mean serum creatinine at the end of the study was 0.57 mg% in children below 12 years and 1.1 mg% in children above 12 years. Patient survival and graft survival at the end of study (mean follow-up of one year) is 100%. Conclusion: Renal transplantation is the treatment of choice for children with end-stage renal disease. The most common causes of end-stage renal disease in children are congenital malformations of the kidneys and urinary tract and chronic glomerulonephritis.


  Late-Onset Sirolimus-Induced Pneumonitis in a Renal-Transplant Patient Top


Yogeshman Anand, Ashwini Gupta

Sir Ganga Ram Hospital, New Delhi, India. E-mail: yogeshmananand2016@gmail.com

Background: We report interstitial pneumonitis caused by sirolimus in a renal-transplant patient 7 years after being started on sirolimus. Our patient presented with fever, cough, and breathlessness. Chest X-ray showed prominent bronchovascular marking and reticular shadowing in bilateral lungs. Bronchoalveolar lavage was negative for infective pathogens. He did not respond to multiple courses of antibiotic therapy. Improvement occurred only upon discontinuation of the sirolimus. Aims of Study: To report late-onset sirolimus-induced pneumonitis in a renal-transplant patient. Background: Sirolimus is known to cause interstitial pneumonitis. Materials and Methods: This is a case report. Results: The entire background put in results. Conclusion: Sirolimus can cause interstitial pneumonitis.


  Successful Second Transplantation after Treatment for Posttransplant Lymphoproliferative Disorder Top


Pallavi Prasad, Dinesh Khullar, Nimish Gupta, Sahil Bagai, Kunal Raj Gandhi

Max Superspeciality Hospital, Saket, New Delhi, India. E-mail: pallaviprasad1986@gmail.com

Background: Posttransplant lymphoproliferative disorder (PTLD) is an uncommon occurrence after kidney transplantation. Immunosuppression and viral infections, especially ebstein barr virus infections, are the two most important risk factors, leading to the development of PTLD. Second transplantation after PTLD is a challenge due to risks of immunosuppression with induction and maintenance agents on the one hand and managing a sensitized transplant on the other hand. Aims of Study: We describe here the case of a boy who underwent successful second kidney transplantation after treatment for PTLD. Methods: A 17-year-old boy was diagnosed with EBV-related diffuse large B-cell lymphoma 1 year after his kidney transplant. In his first kidney transplant, he had received induction with basiliximab. His pretransplant EBV serology was negative. He had a history of receiving ATG for steroid-resistant acute cell mediated rejection in the 1st week after transplantation. He was diagnosed as EBV-related PTLD; after biopsy of a nasopharyngeal mass, he developed 1 year after transplantation. After completion of six cycles of RCHOP, PTLD was in remission but graft function which was initially stable, later worsened due to thrombotic microangiopathy (? cause) and he developed chronic allograft injury and graft loss. Results: After completing 2 years of remission of PTLD, he was planned for second transplant with live-related donor. Pretransplantation EBV IgG was positive. In immunological workup, donor-specific antibodies, flow and CDC crossmatch were negative. Induction agent was basiliximab and he was given pretransplantation rituximab (100 mg) for prophylaxis of PTLD. Maintenance immunosuppression was with tacrolimus, mycophenolate, and prednisolone and he was given acyclovir prophylaxis for prevention of EBV reactivation. Nine months post-transplantation, he maintains stable graft function with no evidence of any infections and complete remission of lymphoma. Conclusion: Choice of immunosuppression in a patient with history of PTLD needs to be made with utmost care. The risks of reactivation of EBV with immunosuppressants need to be weighed against the risk of rejection. Prophylactic rituximab and antivirals have been used to prevent occurrence of PTLD.


  Early Initiation of ACE Inhibitors in Postrenal-Transplant Period: A Study from a State Run Tertiary Care Center Top


V. Akila, L. Umesha, S. M. Shivaprasad, V. Leelavathi, Sreedhara, Kishan

Institute of Nephrourology, Bengaluru, Karnataka, India. E-mail: inunephrology@gmail.com

Background: Renal transplantation is the best treatment for most patients with end-stage renal disease and is associated with significant improvements in quality of life and survival of patients with successful kidney grafts. In patients with stable graft function, ACE inhibitors (ACEIs) may also retain their beneficial effects on reducing left ventricular hypertrophy and proteinuria. Aims of Study: The purpose of this study is to assess the safety of ACEIs, when started in early posttransplant period. Methods: This was a prospective observational study. We reviewed 78 kidney transplant patients from January 2012 to July 2017 at our institution. Sixty-four patients were initiated on ACEI therapy within 4 weeks of post-transplant. Minimum duration follow-up is 6 months. Results: A total of 64 patients were studied, 53 (83%) were male and 11 (17%) were females. The mean age was 32 ± 15 years (12–56). For each patient, hemoglobin, serum creatinine, and potassium levels were analyzed at the beginning of ACEIs and at the end of the 1st, 3rd, and 6th month. Average potassium levels and hemoglobin levels did not differ significantly between groups and were in normal clinical ranges. While incidence of graft failure did not differ, death with functioning graft was lower in the ACEI group. Conclusion: ACEI can be used successfully in postrenal transplant with beneficial long-term impact on renal function. There is need for further randomized controlled studies to see the effect of ACEI on graft function and its survival.


  Interesting Case of Ascites in a Postrenal Transplant Patient Top


V. Akila, L. Umesha, S. M. Shivaprasad, V. Leelavathi, Sreedhara, Kishan, V. Mahesha

Institute of Nephrourology, Bengaluru, Karnataka, India. E-mail: inunephrology@gmail.com

Background: Ascitis in a post-transplant patient can be due to various etiologies. Ovarian tumours are an important etiology in females. Aims of Study: To report interesting case of ascitis in a posttransplant patient. Methods: A posttransplant patient with refractory ascitis was evaluated at a tertiary care center. Results: A 42-year-old female, live-related renal allograft transplant recipient, posttransplant 4 years on triple immunosuppression with stable graft function was admitted with a history of irregular menstrual cycles for 3 months with pain abdomen and abdominal distension. Her ascitic fluid analysis was suggestive of transudative etiology. Oesophago gastro duodenoscopy was normal. Liver function test was normal. Serial CA 125 levels showed elevation from 341 to 654 (after 2 months) and 830 (after 3 months). Contrast-enhanced computed tomography and magnetic resonance imaging abdomen was suggestive of left ovarian simple cyst with moderate ascites and moderate pleural effusion. After 3 months, the patient underwent total hysterectomy with bilateral salpingo-oophorectomy. Histopathological examination of the left ovary was suggestive of benign lesion of the ovary with endometriosis with stromal hyperplasia. Gradually, her ascites came down by the end of 2nd postoperative week. The patient is currently asymptomatic without ascites, without pleural effusion, with normal graft function. Conclusion: Benign ovarian tumors can present with ascitis with elevated CA 125 levels and refractory to therapy in posttransplant patients. Total hysterectomy with bilateral salpingo-oophorectomy may be curative.


  Targeted-Release Formulation-Budesonide in Posttransplant IgA Nephropathy Recurrence Top


V. Akila, L. Umesha, S. M. Shivaprasad, V. Leelavathi, Sreedhara, Kishan, V. Mahesha

Institute of Nephrourology, Bengaluru, Karnataka, India. E-mail: inunephrology@gmail.com

Background: Oral targeted-release formulation (TRF) of budesonide releases the drug in the Peyer's patches in the distal ileum which produces galactose-deficient IgA1. Budesonide is safer due to its extensive first-pass metabolism and <10% of budesonide enters the systemic circulation. The NEFIGAN trial showed reduction in proteinuria with budesonide. We studied the role of budesonide in posttransplant Ig A recurrence and its safety profile. Aims of Study: To study the role of TRF-budesonide in posttransplant Ig A recurrence. Methods: Two patients with posttransplant Ig A recurrence were studied at a tertiary care center. Both patients were started on 9 mg of budesonide with optimization of ACE inhibitors. Patients were followed up with urine routine, renal function, and 24-h urine protein. Results: The first patient was a deceased donor renal allograft transplant recipient on tacrolimus, MMF, and prednisolone. Six months posttransplant, the patient had proteinuria of 10 g with normal graft function. Biopsy was suggestive of Ig A nephropathy with M0E1S1T0C0. The patient was started on oral budesonide 9 mg with optimization of ACE inhibitor and had complete remission within 5 months. Repeat biopsy at 6 months showed a score of M0E0S1T0C0. The second patient was a live-related renal allograft transplant recipient on triple immunosuppression. Two-year posttransplant, the patient had graft dysfunction with proteinuria. Biopsy was suggestive of IgA nephropathy with M0E0S0T0C0. The patient was initiated on 9 mg of budesonide and attained complete remission with normalization of creatinine within 3 months. Both patients are continuing to take budesonide at a dose of 6 mg. No adverse events have been seen in both patients. Conclusion: TRF-budesonide is a specific treatment with favorable safety profile for posttransplant IgA nephropathy recurrence.


  Gastrointestinal Tuberculosis Postrenal Transplant: An Experience from a State-Run Tertiary Care Hospital in South India Top


Megha Pai, L. Umesh, S. M. Shivaprasad, V. Leelavathi, Sreedhara, A. Kishan, V. Akila

Institute of Nephrourology, Victoria Hospital Campus, Bengaluru, Karnataka, India. E-mail: inunephrology@gmail.com

Background: Kidney-transplant recipients are at a high risk of opportunistic infection. Gastrointestinal tuberculosis (TB), although rare in the general population, is about 50 times more frequent in renal-transplant patients. Intestinal TB requires a high clinical suspicion for its diagnosis. Aims of Study: To study the clinicopathological profile of gastrointestinal tuberculosis in postrenal-transplant recipients. Methods: All cases of abdominal TB that occurred in kidney-transplant recipients at our center between 2009 and 2018 were retrospectively reviewed. Detailed demographic data, clinical profile information, and the treatment response were recorded. Results: Among the 131 kidney transplantations performed during the study period, three patients (2.25%) developed abdominal TB. There were two males and one female in the study group. The mean age of the patients was 26 ± 3 years. The time from kidney transplantation to TB was 1.3 ± 0.4 years. The diagnosis was confirmed histopathologically. The ileocecal junction was the most common site involved, followed by colon. All patients received a four-drug regimen of ATT, followed by continuation phase. Two patients developed chronic allograft dysfunction. Symptoms at presentation were fever, weight loss, diarrhea, and abdominal pain. The delay between the identification of the clinical symptoms and the diagnosis was an average of 3 months. Conclusion: Renal transplantation increases the risk of TB, especially extrapulmonary disease. The symptoms of infection are often subtle, leading to delayed diagnosis. Therefore, a careful approach to the patient and supportive evidence are necessary to make the diagnosis.


  Clinical and Microbiological Profile of Patients with Urinary Tract Infection during the First 3 Months after Renal Transplantation Top


Priti Meena, D. S. Rana, A. K. Bhalla, Ashwini Gupta, Manish Malik, Anurag Gupta, Vinant Bhargava

Sir Ganga Ram Hospital, New Delhi, India. E-mail: pritimn@gmail.com

Background: Urinary tract infection (UTI), especially recurrent UTI, is a common problem, occurring in 36%–75% of kidney-transplant recipients, in different series. UTI degrades the health-related quality of life and can impair graft function, potentially reducing graft and patient survival. Our objective was to elucidate the underlying causes, risk factors, and microbiological profile of UTI in renal-transplant recipients in our center. Aims of Study: To study clinical and microbiological profile of patients with UTI during 3-month postrenal transplantation. Methods: This was a prospective observational study, conducted at the Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India. Two hundred and seventy renal transplant recipients were studied over a period of 1 year. All consecutive patients aged >18 years undergoing renal transplantation were included in study. Patients were recruited 2 days before the day of transplant and first urine sample was taken on that day. For analysis of the risk factors predisposing to UTI, detailed clinical history and examination were done of all recipients and donors. Urine microscopy and culture were performed on day 2, every 3 day for first 2 weeks, then in each outpatient department visits (1st, 2nd, 3rd month). An antibiogram relevant to UTIs which represented the different groups of antibiotics (for both Gram-negative and Gram-positive bacteria) was used in susceptibility testing. Risk factors and all the clinic-epidemiological parameters were analyzed using appropriate statistical methods. Results: Of 270 transplant recipients, 99 (36.7%) had UTI. 16/99 (16.2%) UTI patients were undergone ABO-incompatible transplantation. The mean age of patients with UTI was 36.63 ± 10 years. Female transplant recipients had a higher incidence of UTI than males (31/54, 57.4% in females vs. 68/216, 31.5% in males, P < 0.001). 37 (40.35%) patients with UTI had diabetes. Escherichia coli (62.5%) was the most common causative agent. The majority (90.2%) of cases were attributed by Gram-negative bacilli while Gram-positive cocci accounted for 9.8%. Klebsiella pneumoniae was found to be multidrug resistance in most of the cases (95.6%). Underlying urinary tract abnormalities were detected in 20% of patients. In 55 patients (55.6%), episode of UTI was associated with acute graft dysfunction. Older age (P = 0.02), urinary tract abnormality (P < 0.001), female sex (P < 0.001), prolonged Foley's catheterization (P < 0.01), diabetes mellitus (P = 0.02) were statistically significant predisposing factors for UTI, upon multivariate analysis. Conclusion: Older age, female sex, prolonged Foley's catheterization, diabetes, and abnormalities of the urinary tract were the strongest predictors of UTI in posttransplant patients.


  Spontaneous Renal Allograft Rupture of Unknown Etiology: A Case Report Top


Umar Maqbool, Om Prakash, Subodh Kumar, A. Krishna, V. K. Bansal

Department of Surgical Disciplines, AIIMS, New Delhi, India. E-mail: umar777in@gmail.com

Background: Rupture of renal allograft is a rare but serious complication of transplantation. This is usually attributed to acute rejection, acute tubular necrosis, or renal vein thrombosis. This usually occurs during the first 2–3 weeks following transplantation, but cases occurring as late as 65 months have been reported. Aims of Study: NA. Methods: Mr. A. K., a 23-year-old male CKD 5D, underwent live-related renal transplantation (LRRT) using kidney from a 46-year-old donor (mother). The laparoscopic donor nephrectomy was uneventful. Mr. A. K. had an uneventful surgery with usual postoperative recovery. On postoperative day (POD) 0 and POD 1, all parameters were within normal limits including vitals, routine investigations, urine output, and drain output. On POD 2, in morning, there was sudden decrease in urine output to 100 ml/h, albeit with normal routine investigations. Ultrasonography Doppler on the same day evening showed normal color flow in renal artery and renal vein. At around 7 pm, there was sudden increase in drain output with fresh blood as content (500 ml in 10 min) with increased heart rate and slight fall in blood pressure. In view of increased drain output, patient was taken to operating room and re-exploration was done. At re-exploration, the renal allograft was found to have a longitudinal rupture of around 8 cm × 1 cm × 2 cm (length × width × depth) which was bleeding actively. Results: Initial attempt was made to achieve hemostasis and salvage the graft kidney; however, due to uncontrolled bleed, explantation was performed and the graft was removed. Histology showed features of acute tubular injury. However, there was no evidence of acute rejection, ATN, or vascular thrombosis. Conclusion: This case demonstrates that early diagnosis and prompt treatment of a life-threatening condition such as renal graft rupture with explantation of the graft may be required in certain conditions as a life-saving procedure.


  Hyperacute Rejection of a Living-Related Kidney Graft: A Case Report Top


Umar Maqbool, Om Prakash, A. Krishna, Subodh Kumar, V. K Bansal

Department of Surgical Disciplines AIIMS, New Delhi, India. E-mail: umar777in@gmail.com

Background: Hyperacute graft rejection is very rare in kidney transplantation. It is mediated by preformed antibodies that can usually be excluded by a pretransplant CDC crossmatch. The origin of these circulating cytotoxic HLA antibodies is most commonly due to previous failed graft, blood transfusions, or pregnancy. Crossmatches are performed with unseparated cells, T-cells, or B-cells (CDCxM and FCxM). Aims of Study: NA. Methods: We present a case report of a 14-year-old boy, who received an ABO-compatible living-related kidney graft. This was his first kidney transplantation. Pretransplant CDCxM and FCxM results were negative, PRA: Class I: 51% Class II: 0%, DSA to HLA A34 (Jan 2018). Rpt PRA: Class I: 0% Class II: 3% which is not considered a strict contraindication for transplantation. During surgery, no abnormalities occurred. On declamping, kidney was pink and turgid, pulsation and thrill felt across the renal vessels, with good urine output. Clamp on-off time was 45 min. Within 3 min of declamping, kidney became bluish and flaccid with no urine output. Reclamping was done; anastomoses dismantled and kidney reperfused with custodial; no thrombus was seen. Re-anastomosis was done in the same manner. After declamping, kidney was bluish and flaccid, flow across the renal vessels was good with thrill + , but no urine output. Results: In view of suspected hyperacute rejection, two core biopsies were taken from upper pole with BARD 22G biopsy gun. Pathological examination showed thrombotic microangiopathy with arteritis suggestive of hyperacute rejection. Conclusion: Despite all the available immunological examination, certain areas still remain unexplored, and a lot of work is required in this field to make transplant always successful.


  Spontaneous Renal Allograft Rupture of Unknown Etiology: A Case Report Top


Umar Maqbool, Om Prakash, Subodh Kumar, A. Krishna, V. K Bansal

Department of Surgical Disciplines AIIMS, New Delhi, India. E-mail: umar777in@gmail.com

Background: Rupture of renal allograft is a rare but serious complication of transplantation. This is usually attributed to acute rejection, acute tubular necrosis, or renal vein thrombosis. This usually occurs during the first 2–3 weeks following transplantation, but cases occurring as late as 65 months have been reported. Aims of Study: NA. Methods: Mr. A. K., a 23-year-old male CKD 5D, underwent live-related renal transplantation (LRRT) using kidney from a 46-year-old donor (mother). The laparoscopic donor nephrectomy was uneventful. Mr. A. K. had an uneventful surgery with usual postoperative recovery. On postoperative day (POD) 0 and POD 1, all parameters were within normal limits including vitals, routine investigations, urine output, and drain output. On POD 2, in morning, there was sudden decrease in urine output to 100 ml/h, albeit with normal routine investigations. Ultrasonography Doppler on the same day evening showed normal color flow in renal artery and renal vein. At around 7 pm, there was sudden increase in drain output with fresh blood as content (500 ml in 10 min) with increased heart rate and slight fall in blood pressure. In view of increased drain output, patient was taken to operating room and re-exploration was done. At re-exploration, the renal allograft was found to have a longitudinal rupture of around 8 cm × 1 cm × 2 cm (length × width × depth) which was bleeding actively. Results: Initial attempt was made to achieve hemostasis and salvage the graft kidney; however, due to uncontrolled bleed, explantation was performed and the graft was removed. Histology showed features of acute tubular injury. However, there was no evidence of acute rejection, ATN, or vascular thrombosis. Conclusion: This case demonstrates that early diagnosis and prompt treatment of a life-threatening condition such as renal graft rupture with explantation of the graft may be required in certain conditions as a life-saving procedure.


  Comparative Study of Induction Therapy using Antithymocyte Globulin and Basiliximab in Renal-Allograft Recipients: A Tertiary Center Experience Top


Azeem Ahamed, Sandeep Sreedharan, Zachariah Paul, Anil Mathew, George Kurian, Rajesh R. Nair

Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India. E-mail: azeemahamed@gmail.com

Background: Renal transplantation is the treatment of choice for patients with end-stage renal disease, to improve both quality of life and life expectancy. Controlling the alloimmune reaction is imperative for successful renal transplantation. High-dose immunosuppression or induction therapy with antithymocyte globulin (ATG) or basiliximab is used in renal transplantation in the perioperative period to prevent acute rejection and delayed graft function. Aims of Study: In this retrospective study, the efficacy of ATG and basiliximab as induction therapy for renal-allograft recipients were compared along with infection rates in the two groups. Methods: Graft survival and infection rates were compared in 40 patients who underwent renal transplantation in our institute between January 2016 and April 2017. Results: A total of 40 renal-allograft recipients were followed up for 12 months. Thirty patients were male and 10 females. 12.5% of the patients were diabetic. The native kidney disease was presumed chronic glomerulonephritis in 52.5% of the patients, followed by IgA nephropathy (15%) and diabetic nephropathy (12.5%). Graft rejection at any point of time was seen in 15% in the ATG group as against 10% in the basiliximab group. One-year graft survival rates were better in ATG group (25% vs. 60%) (P = 0.025). Urinary tract infections with culture positivity were seen in 55% patients given ATG and 20% patients in the basiliximab group. Conclusion: Graft survival rates at 3 months and 1 year posttransplant were better in the ATG group. Infections including urinary tract infections were higher in the ATG group.


  Posttransplant Lymphoproliferative Disorder Co-Existing with Tuberuloma: A Diagnostic Dilemma Top


A. K. Mohammed Shoeb, K. Vinod Kumar, P. K. Bipi, P. Jojo, V. N. Unni

Aster Medcity, Kochi, Kerala, India. E-mail: drshoeb1988@gmail.com

Background: Solid organ transplant recipients have a higher risk of malignancy and infections. Transplant patients have 20–74 times risk of tuberculosis, when compared to general population. Incidence of posttransplant lymphoproliferative disorder (PTLD) is 1%–4%. Among all PTLD, isolated central nervous system PTLD (CNS-PTLD) has an incidence of 5%–15%. We present a case of deceased donor renal-transplant recipient diagnosed to have co-existing tuberculoma and CNS-PTLD. Aims of Study: The aim is to present a case of CND PTLD with tuberculoma. Methods: Case Report. Results: A 61-year-old male who underwent deceased donor renal transplantation and was given induction with antithymocyte globulin, continued on triple immunosuppression (tacrolimus, mycophenolate mofetil, and prednisolone). He developed new-onset diabetes after transplantation and had multiple infections. He presented with bilateral multiple space occupying lesions on magnetic resonance imaging (MRI) brain. MRI spectroscopy from parietal region was suggestive of tuberculoma. Anti tuberculous therapy was started and the patient improved. He presented after 4 weeks with ataxia and slurring of speech, MRI brain showed regression in lesion of right parietal area, but a new lesion appeared in the left parieto-occipital region along with an enlarged left cerebellar lesion. Decompressive craniotomy and excision of lesion in the left cerebellum were done. Histology confirmed non-Hodgkin's lymphoma, diffuse large B-cell type. He was treated with whole-brain radiotherapy. Repeat MRI brain after 6 months demonstrated a near-total clearance of lesions. Conclusion: Early tissue diagnosis in a solid organ transplant recipient is vital. Low threshold for biopsy in a solid organ transplant recipient would yield good results. This is probably the first case of co-existing tuberculoma with PTLD in renal-transplant recipient.


  Case Report: An Interesting Case of Disseminated Cryptococcal Infection in Kidney-Transplant Recipient Top


Suhas Mondhe, Vikranth Reddy, Santosh Hedau, Srikanth Gundlapalli, Girish Kumthekar, Yuvaraj Sawant

Care Hospitals, Banjara Hills, Hyderabad, Telangana, India. E-mail: drsuhasmondhe@gmail.com

Background: Infectious complications are common in the posttransplant period due to immunosuppressed state. Tuberculosis and bacterial infection are more common as compared to fungal infection. Disseminated fungal infections are often life-threatening. We report a case of disseminated cryptococcal infection presented with cellulitis leg. Aims of Study: To report an interesting case of disseminated cryptococcal infection in a posttransplant recipient. Methods: Case: A 59-year-old male with diabetes mellitus (DM), hypertension, chronic kidney disease (CKD) underwent live-related renal allograft transplant in 2012. Donor was patient's brother. He received no induction agent. He was started on tacrolimus, mycophenolate mofetil, and glucocorticoids. Last creatinine was 3.0 mg/dl. Immunosuppression was modified. The patient had fever, bilateral leg pain, swelling with redness. He diagnosed to have cellulitis. He was started on empirical antibiotics. Wound debridement was done. Encapsulated yeast forms diagnosed in pus and culture confirmed Cryptococcus. Disseminated Cryptococcus infection diagnosed. He was started on fluconazole and lip amphotericin B. Immunosuppression was tapered. Tacrolimus stopped and mycophenolate mofetil decreased. Renal functions worsened. Hemodialysis initiated. Two-dimensional echo diagnosed mobile mass of 0.5 cc on cusps of the aortic valve. Lip amphotericin B was stopped after 2 weeks and fluconazole oral 400 mg/day continued. Patients' wound-healing is good with better renal functions after 3 weeks of treatment. Hemodialysis was stopped. Results: Discussion: Cryptococcus, third-most common fungal infection, involves meninges, lungs, myocardium, bones, joints, urinary tract, and skin and soft tissue. Cryptococcal affects HIV/non-HIV patients. Incidence of cutaneous infection is 10%–20%, and mortality is 25%. Gold standards to diagnose are blood culture and antigen agglutination. Due to polysaccharide capsule, India ink is used (negative staining). Virulence factors are polysaccharide capsule, phenotypic switch, and phenoloxidase enzyme. Necrotizing fasciitis has high morbidity and mortality. Risk factors are DM, CKD, induction agents, and immunosuppression. Incidence in recipients is approximately 2.8% and death rate approximately 42%. Tacrolimus is associated with less central nervous system (CNS) involvement and non-CNS infections are more. Renal failure at admission is independent significant death predictor. Treatment depends on antifungal choice and decreasing immunosuppression. He treated with fluconazole (6 mg/kg/d) for 6–12 months. Injection amphotericin B with/without fluconazole is given. Conclusion: Fungal infections such as Cryptococcus are common in posttransplant patients due to immunosuppression. It involves high mortality. Timely diagnosis and early treatment can save patient and graft.


  Clindamycin with Primaquine for Treatment of Pneumocystis Pneumonia Top


A. K. Mohammed Shoeb, K. Vinod Kumar, P. K. Bipi, P. Jojo, V. N. Unni

Aster Medcity, Kochi, Kerala, India. E-mail: drshoeb1988@gmail.com

Background: Pneumocystis pneumonia (PCP) is an opportunistic infection. Incidence of PCP among solid organ transplant recipients ranges from 5% to 15%, depending on organ transplanted and immunosuppressive regimen. PCP commonly occurs 2–6 months after transplantation. For treatment of PCP, at present, data are scarce for utility of clindamycin and primaquine in renal-transplant recipients. Aims of Study: To study the utility of oral clindamycin and primaquine for treatment of PCP. Methods: This was a case series of three patients. Results: Patient one was started on trimethoprim/sulfamethoxazole (TMP/SMX); he developed low total leukocyte count and was shifted to clindamycin regimen. The other two patients had graft dysfunction and they were started on clindamycin as it has no renal dose modifications. All three patients were treated with oral clindamycin and primaquine for 21 days, they tolerated the drugs well, and no side effects were seen. Conclusion: Clindamycin with primaquine can be considered as a safe and effective option to treat PCP in renal-transplant recipients; this combination can replace TMP/SMX especially in patients with graft dysfunction or leucopenia.


  Pregnancy after Renal Transplant: A Single-Center Experience Top


Harish Prabhu, George Kurian, Rajesh R. Nair, Anil Mathew, S. Sandeep, Zachariah Paul

Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail: harishprules@gmail.com

Background: Success rates of pregnancy among women with chronic renal failure or those on dialysis is very low mainly due to loss of libido, anovulatory vaginal bleeding, or amenorrhea and high prolactin levels. Conception rates and successful pregnancies are extremely low in the above group. Renal transplantation is the best choice for such patients who wants to become pregnant but offers a major challenge because of the complications of immunosuppression, graft survival, and adverse maternal and fetal outcome. Aims of Study: In this review, we are analyzing our experience with postrenal-transplant pregnancies and their outcomes. Methods: All the patients who had successful conception following renal transplantation in our center were retrospectively analyzed. Time period was from 2001 to 2017. Inclusion criteria included all postrenal transplant patients who were in age group 18–36 years. Precocneption creatinine, postdelivery creatinine, graft survival at the end of 6 months and 1 year, maternal complications, and fetal complications were studied. Results: Of total 560 cases of transplant done, 138 were females. Sixty-nine cases were in the age group of 18–36 years. Among them, 22 had conceived in pretransplant and 21 patients conceived postrenal transplant. Of the remaining, 10 were unmarried, seven were nulliparous, two divorced, three died, three lost to follow-up, and one patient had severe graft dysfunction and is back on hemodialysis. Of 21 who became pregnant postrenal transplant, 18 delivered and three are in the antenatal period as of now. The average age of those who conceived was 27 years. Average creatinine preconception was 1.1 mg/dl. Thirteen patients were on dual immunosuppresents while five were on triple immunosuppresents throughout pregnancy. Among fetal complications, two babies preterm and low birth weight each. Two mothers had impending eclampsia and one mother had preclampsia. The mean creatinine at discharge, 6 months, and 1 year was 1.22, 1.34, and 1.37 mg/dl, respectively. One mother had sever graft dysfunction 3 years following transplant and is back on hemodialysis. Conclusion: Successful pregnancy following renal transplant was excellent in our experience. Pregnancy did not affect overall survival graft function. Compared to chronic kidney disease or end-stage renal disease, renal transplant is best choice for those individuals. Proper planning and timing offers the best outcome to mother and fetus.


  Importance of Early Antifungal Therapy in Renal Transplant Patients with Pneumonia: A Case Series Top


Vishnu Dev Urs, Rajesh Nair, Anil Mathew, George Kurian, S. Sandeep, Zachariah Paul

Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India. E-mail: vishnudevurs@yahoo.com

Background: Treatment of pulmonary infections in immunocompromised individuals is emerging as an increasing challenge. This is mainly a result of intensified immunosuppression, prolonged patient survival, the emergence of antimicrobial resistant pathogens, and improved diagnostic assays. Microbiological diagnosis is extremely difficult, and hence, early empirical antibiotic therapy, especially antifungal therapy, will help in the treatment of these patients. Aims of Study: To analyze the treatment outcome of eight renal-transplant patients with pulmonary infiltrates and their treatment regimens in the intensive care unit over a period of 6 months. Methods: This was a retrospective observational, cross-sectional study, involving analysis of eight renal-transplant patients with pulmonary infiltrates and their treatment regimens in the intensive care unit (ICU) over a period of 6 months (December 2017 to May 2018). Results: Eight renal-transplant patients who presented with bronchopneumonia, requiring ICU admission were included in the study. Six patients were men and two patients were women. The average period of immunosuppression was around 4–5 years. Mean age was around 50 years. Seven out of eight patients were on triple immunosuppression (tacrolimus, MMF, and prednisolone). The average serum creatinine was around 2.2–2.5 mg/dl. All eight patients presented with history of cough, fever, and breathlessness of 2–3 days duration and were found to have bronchopneumonia and septicemia. They were evaluated on similar lines with computed tomography chest and bronchoscopy. Blood, urine, and bronchoalveolar lavage samples did not reveal any microbiological diagnosis in the first 1 week. All eight patients were empirically treated with broad-spectrum intravenous (IV) antibiotics (piperacillin tazobactam or meropenem), antifungals (fluconazole), and cotrimoxazole (for pneumocystis jiroveci pneumonia). Six out of eight patients required invasive ventilation. Immunosuppression was modified on an individual basis. In two patients, IV echinocandins (anidulafungin) were started within 72 h of admission. Both these patients showed good clinical improvement and had complete radiological clearance of pulmonary infiltrates. The other patients showed no significant improvement and subsequently expired. The mean duration of hospital stay was around 2–3 weeks. Conclusion: Early IV echinocandins may be an important factor in the successful outcome of renal-transplant patients with pneumonia. Obtaining a microbiological diagnosis may be difficult and hence empirical antifungal therapy is probably the need of the hour in the treatment of these patients.


  Impact of Clinical Parameters and Vascular Hemodynamics on Outcome of Arteriovenous Fistula: A Prospective Study Top


Om Prakash, Nalinikant Ghosh, H. K. Bhattacharie, A. Krishna, V. K. Bansal

Department of Surgical Disciplines AIIMS, New Delhi, India. E-mail: drprajapatiom@gmail.com

Background: Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD) in chronic kidney disease patients. It is economical, durable, and associated with less complications. However, a significant number AVFs (30%–60%) fail to mature for HD. Various demographic and patient-related factors (clinical and screening Doppler) have influence on maturation of AVFs. Aims of Study: This study is designed to assess the incidence of AVF maturation and the factors associated with poor outcome. Methods: This is a prospective observational study of all radio-cephalic AVF (RCAVF) between April 2015 and July 2016 in a tertiary care center. Clinical and Doppler sonography parameters were recorded. RCAVFs were made with end-to-side anastomosis under local anesthesia. Patients were followed for 6 months. Successful consecutive six sessions of dialysis using fistula within 6-month follow-up was regarded as matured AVF. Results: A total of 259 patients underwent RCAVF creation and 54 patients were excluded. A total of 205 patients met the inclusion criteria and were analyzed. 150 (73.2%) patients met the definition of maturation. Patient's body mass index (BMI), presence of diabetes, radial artery diameter of >2 mm and immediate postoperative thrill had positive impact on maturation of AVF (P < 0.001); however, age, sex, serum creatinine, and hypertension were not significantly associated with failure. Conclusion: AVF has a success rate of 73.2% in our setting without any radiological intervention. Low BMI, presence of diabetes, radial artery diameter >2 mm, and presence of thrill postoperatively were important predictors of successful outcome following AVF creation.


  A Prospective Study Assessing the Learning Curve in Complex Laparoscopic Procedures Top


Om Prakash, Devanshu Bansal, A. Krishna, K. Subodh, M. C. Misra, V. K Bansal

E-mail: drprajapatiom@gmail.com

Background: Laparoscopic donor nephrectomy is a complex laparoscopic operation which requires advanced laparoscopic skills and dexterity because of the delicate nature of various structures and the organ which needs to be preserved so that the graft can perform optimally in the recipient. The vascular structures and ureter need to be handled carefully because of increased complications if proper harvesting is not done. Such complex procedure entails a significant learning curve with it. Aims of Study: This study was done to estimate our learning curve associated with this complex surgical procedure. Methods: This prospective study was undertaken between January 2013 and January 2015. 100 patients were included. A Precepter-Proctorship model was used to learn this procedure. Patients undergoing open donor nephrectomy were kept as the control group. Data recorded included demographic profile, preoperative and intraoperative variables, postoperative complications, hospital stay, pain, quality of life, and graft outcome. The cost for each procedure was also calculated. Learning curve was calculated using the moving average method and calculating the average of operative time of every five consecutive cases. The learning phase was considered overcome when the moving average of operative times reached a plateau and when the mean operative time of every five consecutive cases reached a low point and subsequently did not vary by >30 min. Results: The demographic profile was comparable between the two groups. The mean operative time of the laparoscopic procedure was 108.1 ± 26.5 min (range 60–180 min). Learning curve of LDN as measured by the moving average method was achieved at around 20 cases and between 26 and 30 cases according to the mean operative time of every five consecutive cases. Only few minor intraoperative visceral injuries were encountered and all could be managed laparoscopically. Two cases required conversion to open, both being within the learning curves. Conclusion: LDN is a complex surgery and has a learning curve associated with it. However, this curve can be overcome with proper training and guidance.


  Rare Case Report of Postrenal Transplant Azilsartan-Induced Thrombocytopenia Top


Nimish Gupta, Dinesh Khullar, Pallavi Prasad, Sahil Bagai, Kunal Raj Gandhi

Max Superspeciality Hospital, Saket, New Delhi, India. E-mail: nimish392005@gmail.com

Background: Postrenal-transplant thrombocytopenia can be attributed to number of causes including induction agents, maintenance immunosuppression, especially mTOR inhibitors, infection prophylaxis, microangiopathies, acute rejection, and drugs. Detailed clinical examination and high degree of suspicion for drug-induced thrombocytopenia may help achieve the correct diagnosis. Aims of Study: To report azilsartan as a rare cause of drug that induced thrombocytopenia in postrenal-transplant patient. Methods: Azilsartan-induced thrombocytopenia was diagnosis of exclusion and other possible causes of posttransplant thrombocytopenia were ruled out after thorough workup. Peripheral blood smear revealed isolated thrombocytopenia with no features of microangiopathy. Everolimus was switched to tacrolimus, and there was no other drug which may commonly cause thrombocytopenia. Vitamin B12 folic acid levels were normal. Viral markers were negative. Bone marrow aspiration showed Myeloid: erythroid ration of 2.8:1 with adequate megakaryocytes. Bone marrow biopsy showed trilineage hemopoesis with normal morphology of megakaryocytes. Parvovirus DNA PCR was negative. After stopping azilsartan, thrombocytopenia gradually improved. Results: A 32-year-old male, known case of diabetes mellitus type 1 with diabetic nephropathy. He underwent live-related renal transplant on July 29, 2016, with father being donor and rabbit ATG was used as induction agent. In January 2017, the patient developed acute CMV disease. Antimetabolites were stopped and he was adequately treated with oral valganciclovir for 1 month. In April 2017, the patient had gradual rise in serum creatinine, for which graft biopsy was done which was suggestive of calcineurin toxicity. Tacrolimus was stopped and he was started on everolimus. The patient also developed proteinurea – 500 mg/day for which azilsartan was started. In February 2018, the patient presented in emergency with epistaxis, gum bleeding with platelet count of 4000/μl. Everolimus was switched to tacrolimus again, but thrombocytopenia persisted. Bone marrow examination was normal and parvovirus B19 was negative. Azilsartan was stopped and platelet count gradually improved to normal level. Conclusion: Meticulous workup and study of possible drug interactions are required to diagnose posttransplant thrombocytopenia.


  Postrenal Transplant Oxalosis: A Case Report Top


B. Karthikeyan, M. Edwin Fernando, N. D. Srinivasa Prasad, Sujit, Vivekpraveen, K. Thiruma Valavan

Government Stanley Medical College, Chennai, Tamil Nadu, India. E-mail: drbkarthikeyanstanley@gmail.com

Background: Intratubular crystal deposition in transplanted kidney is very rare and can be a cause of renal graft failure. Primary hyperoxaluria (PH) is a rare autosomal recessive disease resulting from deficiency of hepatic alanine: glyoxylate aminotransferase (AGT) (type I, PH-I) or glyoxylate reductase/D-glycerate dehydrogenase (type II, PH-II). Recurrence of PH in renal transplants is common. In a few patients, very rapid recurrence of disease has also been described. Aims of Study: We report a case of immediate graft dysfunction due to oxalosis by rapid intratubular calcium oxalate crystal deposition in renal allograft, with the diagnosis being made only after transplantation (Tx). Method: A 41-year-old male with chronic kidney disease-end-stage renal disease on maintenance hemodialysis for 28 months before transplant, with no previous history of renal stone disease; he underwent live-related renal transplant with sister as donor in March 2018. Intraoperatively, he had anastomotic leak with significant blood loss resulting in hypotension necessitating inotropic support and blood product transfusion. He was started on triple immunosuppression without induction. He had delayed graft dysfunction in postoperative; renal allograft biopsy done showed acute tubular injury with some oxalate crystals. He continued to be dialysis dependent; subsequent renal biopsy done showed persistent acute tubular injury with oxalate crystals. We suspected PH and initiated daily hemodialysis with pyridoxine therapy. Despite 10-day intensive hemodialysis, his renal function did not improve and became dialysis dependent. Due to logistic issues, we did not done genetic workup for oxalosis. Result: After successful renal Tx, a large amount of Ox is excreted into urine and the serum Ox level returned to normal between 3 days and 3 weeks post-Tx in all patients whose original renal diseases are not PH. These considerations suggest that increased tubular load of Ox is routinely expected in the immediate post-Tx period, and Ox may precipitate in tubular cell or tubular lumen. Because only a small percentage of unselected renal Tx biopsies (around 4% in this study) showed CaOx, additional pathogenetic factors may be involved. ATN may facilitate CaOx deposition as suggested by the presence of CaOx in 10/13 Tx biopsies with ATN reported by Olsen et al., in four out of five grafts with “ischemic necrosis” reported by Memeo et al. We initially thought that renal dysfunction due to ischemic ATN-induced oxalate crystals but subsequent renal biopsy was more in favor of oxalate neohropathy. Posttransplant computed tomography kidney-ureter-bladder taken showed 2-mm left pelvic calculi with bilateral contracted hyperechogenic kidneys. Conclusion: We present the case, a patient with acute kidney allograft dysfunction secondary to oxalosis. This case emphasises the need to rule out primary Hyperoxaluria in every case of renal stone disease. If we evaluated thoroughly in pretransplant to identify his native kidney disease, we could averted this mishap.


  Study of Outcome of Living Kidney Donors Top


Mondhe Suhas, Vikranth Reddy, Santosh Hedau, Srikanth Gundlapalli, Girish Kumthekar, Yuvaraj Sawant, G. Lakshmi

Care Hospitals, Banjara Hills, Hyderabad, Telangana, India. E-mail: drsuhasmondhe@gmail.com

Background: Kidney transplantation is the treatment of choice for advanced chronic renal failure. Safety of the renal donors is not established. Factors such as age, gender, comorbidities, and familial predisposition influence donor's renal functions. In a resource-limited setting, like India, it is important to understand the risk involved in renal donation. The paucity of Indian studies prompted us to evaluate the effects of donation on blood pressure (BP), proteinuria, and glomerular filtration rate in voluntary kidney donors. Aims of Study: To study renal dysfunction, hypertension, and proteinuria in voluntary kidney donor. Method: This was a prospective, observational, comparative study. Study Duration: 2 years (May 2015 to May 2017). Inclusion Criteria: (1) The voluntary renal-transplant donors undergoing predonation evaluation, surgical procedure, and postdonation follow-up. Exclusion criteria: (1) Renal dysfunction and proteinuria in donors due to acute kidney injury were excluded. We compared presurgery and postsurgery renal parameters, BP, and proteinuria (four times follow-up) using paired t-test (quantitative). P < 0.05 was considered significant. Study Design: Blood samples were collected predonation postdonation follow-up visits at the end of 1st, 2nd, and 4th week followed by 6 months postnephrectomy. Donors were analyzed for serum creatinine, serum proteins, serum albumin, and glomerular filtration rate (CKD-EPI Method). Urine samples were collected for the spot urinary protein-creatinine ratio. Vitals measurements (pulse, BP) general and systemic examination were recorded. Results: In 2 weeks, 35%–40% donors developed a decrease in Hb. It gradually improved, and at 6 months, only one donor had a significant drop in Hb (0.5 g/dl). Average systolic BP of donors decreased from predonation 124.38 to 121.19 mm of Hg at 6 months. Statistically insignificant was observed. No significant change in the diastolic BP was observed. Average creatinine increased significantly from 0.85 to 0.94 mg/dl over 6 months. Estimated glomerular filtration rate (eGFR) decreased from 95.73 to 76.35 ml/min/1.73 m2 BSA in the 1st week postdonation. eGFR significantly increased from 76.35 to 87.16 ml/min/m2 BSA over 6 months. At 6 months, two patients were in the CKD (3a) stage. Over 6 months, eGFR achieved by donors was 91% predonation eGFR which is 65% in compared studies. Significant proteinuria was not observed during follow-up. Conclusion: During follow-up in voluntary kidney donors, there was no significant drop in Hb. There was no significant hypertension or proteinuria. 6%–7% donors developed CKD (3a).


  Successful Outcome of Transplanting a Kidney from an HCV-Positive Deceased Donor into an HCV-Negative Recipient Top


Hepal Vora, Zaheer Virani

Global Hospitals, Mumbai, Maharashtra, India. E-mail: drhepalvora@gmail.com

Background: The discovery of direct-acting antiviral therapy has revolutionized the treatment of hepatitis C. With DAA-based interferon-free regimens, one can treat hepatitis C in end-stage kidney disease posttransplant as well. There is a paucity of data regarding transplantation of kidneys from HCV-infected donors into HCV-negative recipients. We report a case of sequential liver and kidney transplantation in which a HCV-negative recipient received a kidney from a HCV-infected deceased donor. Aims of Study: To study the successful outcome of transplanting a kidney from an HCV-positive deceased donor into an HCV-negative recipient. Methods: A 53-year-old male with type 2 diabetes mellitus for 25 years was diagnosed with hepatitis C-positive chronic liver disease in 2007. He was incompletely treated with interferon and ribavirin due to intolerable side effects. He then developed decompensated liver disease and underwent deceased donor liver transplant on September 20, 2013. In September 2014, he presented with nephrotic range proteinuria and microscopic hematuria. Serum creatinine was 1.18 mg/dl and ultrasound of the kidneys was normal. The C3 level was 89 mg/dl; antinuclear antibody and cryoglobulins were negative. Kidney biopsy revealed features of membranoproliferative glomerulonephritis, and immunofluorescence showed predominantly immunoglobulin M and C3 positivity in capillary glomerular loops, consistent with HCV-glomerulopathy. He was treated with sofosbuvir and ribavirin, and by 12 weeks, his HCV RNA was negative. However, his renal function deteriorated, and in June 2016, he was initiated on maintenance hemodialysis. Results: On December 10, 2017, we received a call for a kidney from a HCV-positive brain-dead donor. One kidney was accepted by a center that had a HCV-positive recipient. We discussed with the patient about the risk of contracting HCV infection and the possibility of treating infection after transplant. He accepted the offer, signed the informed consent, and the renal transplant was performed. At this time, he had normal liver allograft function. Induction agent was methylprednisolone and two doses of basiliximab (20 mg each). Maintenance immunosuppression was prednisolone, tacrolimus, and MMF. Later, MMF was replaced by azathioprine as he developed intolerable gastrointestinal side effects. The donor's hepatitis C viral load was 19,789,048 copies/ml. The recipient's HCV RNA was undetectable before kidney transplant, and 1 week after transplant, it was 992,920 copies/ml. Once his renal function stabilized with glomerular filtration rate of >30 ml/min/1.73 m2, he was treated with a dual oral regimen of daclatasvir plus sofosbuvir. His viral load was undetectable at 4 weeks, and he attained a sustained virologial response (defined as aviremia 24 weeks after completion of antiviral therapy). Conclusion: Organs from hepatits C-positive deceased donors can be successfully transplanted with assurance of achieving viral negative status with newer antivirals. This can help in increasing the pool of deceased donor organs.


  Single-Center Experience of 50 ABO-Incompatible Renal Transplants Top


Aniketh Prabhakar, Sishir Gang, Umapathi Hegde, Abhijit Konnur, M. M. Rajapurkar, Hardik Patel

Muljibhai Patel Urology Hospital, Nadiad, Gujarat, India. E-mail: anikethprabhakar@gmail.com

Background: Transplantation across the ABO blood group barrier helps expands the options for living kidney donations. With renewed interest in ABO-incompatible kidney transplant (ABO I KTx), paucity of outcome data especially in comparison to ABO-compatible transplant (ABO C KTx) exists in the Indian Subcontinent. We analyzed 50 ABO I KTx with matched controls (ABO C KTx) from our center. Aims of Study: To study outcomes of 50 ABO-incompatible Renal Transplants at our center and compare its outcomes with ABO-compatible transplants. Methods: Fifty ABO I KTx and fifty ABO C KTx matched with age, donor relationship, and time of transplant were analyzed in this observational single-center study. The patients undergoing ABO I KTx were subjected to a fixed desensitization protocol with rituximab 375 mg/m2 given 15 days before transplant and subsequent antibody removal using various methods to bring the pretransplant ABO titers to 1:8 or lesser. Induction immunosuppression was at clinician's discretion and the maintenance immunosuppression was with CNI, MMF, and steroids. Postoperative titers and postoperative plasmapheresis were performed if indicated. Primary outcomes were patient and allograft survival, incidence of rejection, and secondary outcomes such as infections, effect of HLA mismatch, and difference between blood groups were assessed. Results: The median follow-up for ABO I and ABO C KTx patients was 22 and 24 months, respectively. There was a significantly (P = 0.028) higher incidence of humoral rejection in the ABO I KTx group, but estimated graft survival at 5 years was 76% and 86% and patient survival was 82% and 94%, respectively, in ABO I KTx and ABO C KTx group (P = 0.45 and 0.48). Infectious and malignancies were comparable in both groups. Subgroup analysis revealed no significant differences in graft survival between O and non-O blood groups or if titers were >1:64 or lesser. Conclusion: The comparable graft survival shows that this option is noninferior to control group. No significant increase in infection in these transplants despite increased immunosuppression was demonstrated. With adequate resources, ABO I KTx is a safe and reasonable alternative to reduce organ shortage.


  Rose Gardener's Disease (Sporotrichosis): A Rare Presentation of Fungal Infection Postrenal Transplant Top


Amandeep Singh, Vikas Makkar, Suman Sethi, P. M. Sohal, Simran Kaur

Dayanand Medical College, Ludhiana, Punjab, India. E-mail: dr.amandeepsingh85@gmail.com

Background: Fungal infections, including candidiasis, cryptococcosis, and aspergillosis, occurs in 9%–14% of patients following a renal transplant and varies according to the geographical area. Sporotrichosis, also known as rose gardeners disease, is rare in renal-transplant recipients. We report a case of renal transplant recipient presenting with sporotrichosis. Aims of Study: To report rare case of postrenal-transplant fungal infection – sporotrichosis. Methods: A 40-year-old male received renal allograft from his spouse in March 2017. After about 1 year, he presented with skin lesions below his left knee in form of violaceous papules coalescing to form plaques for 1 month. His skin biopsy was done which revealed sporotrichosis. Results: The patient was treated with oral itraconazole for 6 weeks and responded to treatment. Conclusion: Fungal infections including candidiasis, cryptococcosis, and aspergillosis are common in postrenal-transplant patients. Sporotrichosis is a rare and easily treatable entity which should be considered in differential diagnosis of fungal infections in transplant patients.


  Hematuria in Postrenal-Transplant Recipient: A Rare Cause Top


Gowthaman Ganesan, N. D. Srinivasaprasad, M. Edwin Fernando, S. Sujit, K. Thirumalvalavan, R. Vivek Praveen

Government Stanley Medical College Hospital, The Tamil Nadu Dr. M. G. R. Medical University, Chennai, Tamil Nadu, India. E-mail: gowsidr7227@gmail.com

Background: Hematuria has a prevalence of 12% in postrenal-transplant recipient population. A major cause of hematuria is urinary tract infection. Adenovirus a common pathogen has a potential to cause opportunistic infection with significant morbidity and mortality. Reported adenovirus infection in renal-transplant recipient has typically manifested as hemorrhagic cystitis and tubulointerstitial nephritis. Aims of Study: Here, we report a case of Adenovirus-induced hematuria in a postrenal-transplant recipient. Methods: A 48-year-old male underwent ABO-compatible LRRTR with brother as donor on February 6, 2013. No induction agent was used. He had stable graft function with triple immunosuppression. Five years after transplant, he presented with macroscopic hematuria. The physical examination was unremarkable. Investigations revealed hemoglobin-15.2 mg/dl, TC: 7700/cumm, polymorphs: 75%, lymphocytes: 11%, monocyte: 13%, and creatinine: 2.4 mg/dl. Urine Routine: Protein: 2+, Blood: 3+ LEU/NIT – negative. Urine C/S: no growth. CT KUB: periuretric fat stranding in transplanted kidney – suggestive of pyelonephritis. Severe perivesical fat stranding – suggestive of cystitis. In view of persistent hematuria, qualitative PCR assay for adenovirus was sent which turned out to be positive. With reduction of immunosuppression, macroscopic hematuria disappeared and graft function improved. Results: Asymptomatic adenovirus infection is defined by detection of virus in urine, blood, stool, or upper airway specimens by viral culture, antigen test, or polymerase chain reaction (PCR) in the absence of sign and symptom. A role of immunosuppression in particular induction therapy, as a risk factor for adenovirus infection, is supported by the high rate of Adenovirus infection in 1st month after transplantation. In addition, development of adenovirus has been associated with treatment for acute rejection. Clinical Features: hemorrhagic cystitis-fever, dysuria, urgency, frequency, and gross hematuria were observed. Hemorrhagic cystitis is usually accompanied by allograft dysfunction. The most common diagnostic tool is amplification and detection of viral genome by PCR. In many patients reduction of immunosuppression leads to resolution of disease. Reduction of immunosuppression with specific antiviral therapy is the strategy recommended for adenoviral infection. Ribavirin and cidofovir may be used. Conclusion: As our patient had macroscopic hematuria with mild graft dysfunction, Adenovirus infection was suspected which was proved by qualitative PCR. With reduction of immunosuppression, hematuria resolved and graft function improved. This case is presented for its rarity.


  Extradural Mass: Aspergilloma In Renal-Transplant Recipient Top


Manpreet Kaur Jhingar, Vikas Makkar, P. M. Sohal, Suman Sethi, Simran Kaur

Dayanand Medical College, Ludhiana, Punjab, India. E-mail: dr.manpreetjhingar@gmail.com

Background: A 55-year-old renal-transplant recipient with date of transplantation December 12, 2017 started to develop lumbar backache along with progressive lower limb weakness with duration of 1 month which was followed by acute onset of weakness of lower limbs along with bowel and bladder dysfunction. Aims of Study: To report the uncommon variant of central nervous system infection in renal-transplant patients. Methods: Neurological examination showed flaccid paralysis with decreased tone. He had evidence of radiculopathy with absent reflexes, impaired sensory loss in both limbs along with sensory level. He underwent magnetic resonance imaging (MRI) spine which showed infiltrative mass lesion involving posterior elements of D11–D12 vertebrae. Results: Ultrasonography-guided trucut biopsy was taken and sent for histopathological examination. Findings were suggestive of aspergillosis. He was treated with oral voriconazole for 4 weeks and repeat MRI showed resolution of mass. Conclusion: Resolution of extradural mass was identified.


  A Patient of Third Kidney Transplantation with ABO and HLA Antibodies Top


Kaustuv Mukherjee, Deepak Shankar Ray, Nidhi Singh, Nikhil Shinde, Anand Prasad, Rabi Ranjan Sow Mondal, Manoj Gupta, Himadri Shankar, Ratnesh Rokde

Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, Kolkata, West Bengal, India. E-mail: kaustuvda@gmail.com

Background: Transplantation is the best modality of treatment that can be offered to a person suffering from end-stage renal disease (ESRD). With increasing prevalence of ESRD, improving graft and human survival on transplantation (Tx), and increased availability of healthcare facilities providing living donor kidney transplant in the country, more people are opting for it. Consequently, barriers to multiple Tx are emerging problems to transplant physicians and surgeons. Aims of Study: Not applicable. Methods: A 30-year-old nondiabetic lady a known patient of chronic kidney disease possibly from reflux nephropathy presented for third renal Tx. She was diagnosed to have ESRD in 1999 and received two allografts from two altruistic ABO-compatible donors. She developed biopsy-proven chronic allograft nephropathy and wanted a pre-emptive Tx. Her mother was the donor. Investigation revealed her blood group as B not compatible with her daughter's blood group O. In addition, she also had raised anti-HLA antibody against both class I and II of her mother's antigen. She was received rituximab and commenced on regular immunosuppression, tacrolimus, mycophenolate, and prednisolone 2 weeks before Tx. She was then commenced on plasma exchange (PE) and a dose of intravenous immunoglobulin after each session of PE from 7 days before operation theater. The recipient received two doses of methylprednisolone of 500 mg each followed by rabbit antithymocyte globulin as induction immunosuppression. There were surgical issues as well. Results: Postoperative period was uneventful and the recipient was discharged with normal renal function and is doing well at follow-up at 3 months. Conclusion: As far as we are aware, any repeat (third) pre-emptive kidney Tx with both HLA and ABO antibodies has not been done before. Our case shows that simple, affordable, low-cost desensitization can bring success outcome in a highly sensitized patient with third Tx.


  Synchronous Posttransplant Lymphoprolifrative Disorder and Tuberculosis Top


Amandeep Singh, Vikas Makkar, P. M. Sohal, Suman Sethi, Simran Kaur

Dayanand Medical College, Ludhiana, Punjab, India. E-mail: dr.amandeepsingh85@gmail.com

Background: Postrenal-transplant infections are common with incidence of postrenal-transplant tuberculosis (TB) 12.3% in India. Posttransplant lymphoprolifrative disorder (PTLD) is uncommon with incidence of 1.45% in North India. Synchronous presentation of PTLD and TB is rare. Aims of Study: To report the case of synchronous PTLD and TB in renal-allograft recipient. Method: A 21-year-old male received renal allograft from his father in November 2017. On follow-up, he presented with fever and cervical lymphadenopathy and was diagnosed with TB lymphadenitis. After few days, he had inguinal lymph node enlargement which revealed PTLD. Results: He was treated with antitubercular drugs along with reduction of immunosuppression. However, he did not responded to treatment and expired. Conclusion: Postrenal transplant TB is common in India and PTLD is uncommon. Synchronous presentation of PTLD and TB is very rare and should be kept in mind.


  Chronic Antibody-Mediated Rejection: A Single-Center Experience Top


Adelene Teena Manuel, Noble Gracious

Department of Nephrology, Government Medical College, Trivandrum, Kerala, India. E-mail: drteenamanuel@gmail.com

Background: Chronic antibody-mediated rejection (CAMR) is the main cause for late kidney transplant loss, and the results of its treatment are dissatisfying. Out of the 198 transplant biopsies done in the last 5 years in our institution, 13 patients had CAMR (6.5%). This is superior to the Moscow Nephrology Centre Renal Biopsies Registry in which CAMR was diagnosed in 171 cases out of 1360 kidney-transplant biopsies over the last 10 years, which constituted 12.6%. Aims of Study: (1) To analyze the demographics, laboratory data, and pathology of CAMR patients. (2) To analyze the association between various risk factors and occurrence of CAMR. (3) To study the outcomes of CAMR treatment. Methods: We compared a group of 13 patients having CAMR with a control group of 13 posttransplant patients without CAMR. Age and time period after transplantation were matched. The variables analyzed include inadequacy of calcineurin inhibitors levels, absence of diabetes mellitus, proteinuria, C4D positivity, de novo DSA, azathioprine use, history of acute rejection, and use of induction agents. Statistical analysis was performed using SPSS program package. Odds ratio analysis was done. P < 0.05 was defined for statistical significance. We also studied the various outcomes of CAMR treatment in our patients which includes incidence of infections and rate of estimated glomerular filtration rate (eGFR) loss after treatment with a combination therapy of plasma exchange (PLEX), intravenous immunoglobulin (IVIg), and rituximab. Result: From our study, we could find a significant association between occurrence of CAMR and only two variables: inadequacy of CNI levels and absence of diabetes mellitus. Other variables studied include proteinuria, C4D positivity, de novo donor-specific antibody (DSA), azathioprine use, history of acute rejection, and use of induction agents. Three CAMR patients did not receive treatment due to death from life-threatening infections. All the remaining patients received IVIg, PLEX, and rituximab ± bortezomib. Median eGFR loss rate was 5.425 ml/min/year. Infections occurring after treatment include Staphylococcus aureus Scientific Name Search  abscess, burkholderia pneumonia, pulmonary tuberculosis, hepatitis B and C, multidrug-resistant Klebsiella and Catheter Related Blood stream infection and Ebstein Barr Virus infection. The treatment outcomes suggest an unfavourable prognosis. Conclusion: Inadequate CNI levels and absence of diabetes mellitus have shown to have a significant correlation with occurrence of CAMR in our study. Routine surveillance for de novo DSA, periodic monitoring of CNI levels, and continuation of MMF, instead of conversion to azathioprine, are warranted.


  Prospective Data on Changes in Cardiac Structure and Functional Parameters in Renal-Allograft Recipients Top


Manpreet Kaur Jhinger, Vikas Makkardr. P. M Sohaldr, Simran Kaur Chahaldr, Suman Sethi

Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail: dr.manpreetjhingar@gmail.com

Background: Prospective data on changes in cardiac structure and functional parameters in renal-allograft recipients are scanty. Our hypothesis is that there should be improvement in cardiac function after renal transplantation. Aims of Study: To study the structural and functional cardiac parameters before and after renal transplantation by echocardiography. Methods: Thirty renal-allograft recipients will be included. Patients with valvular heart disease and coronary artery disease will be excluded. Echocardiography will be done before renal-transplant surgery and repeated at 3 months and if possible 6 months after renal transplantation. Changes in the structural and functional cardiac parameters before and after renal transplantation on echocardiography will be analyzed and correlated. Results: Mean left ventricle ejection fraction before and after renal transplantation was 53.83% ± 10.14% and 57.33% ± 4.49%, respectively (P = 0.09). Left ventricular hypertrophy existed in 46.7% patients, which was improved in 30% after renal transplantation. Conclusion: It is suggested that renal transplantation could improve left ventricle parameters in patients with end-stage renal disease after renal transplantation.


  An Unusual Cause of Paraplegia in a Renal-Transplant Recipient Top


T. Sugan Gandhi, T. Dineshkumar, R. Shakthirajan, J. Dhanapriya, V. Murugesan, N. Malathy, T. Balasubramaniyan, N. Gopalakrishnan

Institute of Nephrology, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: sugandevan16@gmail.com

Background: Posttransplant lymphoproliferative disorders (PTLDs) are lymphoid or plasmacytic proliferations occurring in solid organ0transplant recipients as a result of immunosuppression. Majority of these tumors are B-cell lymphomas. There are very few case reports of T-cell PTLD presenting as acute compressive myelopathy. Case Report: A 35-year-old woman who underwent living-related renal transplant (LRRT), 7 years ago, presented with back pain and acute-onset weakness of both lower limbs. Aims of Study: Her renal allograft had an angiomyolipoma which neither increased in size nor affected the graft function. She was on triple immunosuppressant therapy (CSA/MMF/PDN) and had normal graft function. Methods: Her motor power was 0/5 in both lower limbs with hypotonia and absent reflexes. All modalities of sensation were lost below the inguinal region with no bladder or bowel involvement. Magnetic resonance imaging spine revealed an extraosseous soft tissue lesion extending into epidural space causing severe canal stenosis and cord compression at D12–L1 level. Similar soft tissue lesions were seen in D5 and L4 vertebrae level without spinal cord compression. Computed tomography-guided biopsy of the lesion revealed diffuse sheets of intermediate-sized lymphoid cells with irregular nucleus which were CD3 and CD4 positive and CD20 negative on immunohistochemistry study. There was neither dissemination of the disease in positron emission tomography scan nor marrow involvement in bone marrow study. Her Ebstein–Barr Virus (EBV) DNA serology was negative. Results: She was treated with reduction of immunosuppressants, radiotherapy, and chemotherapy (CHOP regimen). Repeat imaging revealed significant resolution of the lesion and her muscle power improved to 3/5 in both lower limbs. Discussion: Unique Features in Our Case: The graft angiomyolipoma neither increased in size nor affected the graft function during 7 years of follow-up. T-cell EBV-negative PTLD are quiet rare. They generally present late similar to our patient and are very virulent, but our patient is surviving for 8 months since the diagnosis of PTLD with stable graft function. Similarly, involvement of the spine is extremely unusual. To the best of our knowledge, this is the first case report of T-cell lymphoma presenting as extradural mass with cord compression in renal-transplant recipients. Conclusion: PTLD can present late, especially EBV-negative T-cell lymphomas, and although spinal involvement is rare, PTLD should be considered in the differential diagnosis of acute compression myelopathy in renal-transplant recipients.


  An Uncommon Complication in an Unusual Presentation in Renal-Transplant Setting Top


Girish P. Vakrani

Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. E-mail: drvakranis@gmail.com

Background: Postoperative period in renal transplantation setting can have various medical and surgical complications. Utmost suspicion of such complications should be kept in mind in early graft dysfunction. Aims of Study: To narrate about an uncommon complication in an unusual presentation in renal-transplant setting. Methods: A spousal renal-transplant recipient on the 5th day posttransplant had undergone graft biopsy for delayed graft function with all precautions. He had bloated abdomen, worsening hematocrit, worsening renal parameters since postsurgery before biopsy. Results: He developed huge perigraft collection/hematoma extending extensively. Conclusion: A computed tomographic scan followed by emergency exploration revealed rather a bleeder from drain site which had slipped incidentally from its position indeed. The patient was stabilized. Graft biopsy revealed severe acute tubular necrosis. He recovered well from surgical complications and graft dysfunction too.


  A Study of the Influence of Preoperative Factors on Graft Function in Renal-Allograft Recipients Top


Sreedhar Sharma, K. Praveen Kumar, Varaprasad Rao, Raghavendra Sadineni

Narayana Medical College, Nellore Andhra Pradesh, India. E-mail: chinmayesapre16@gmail.com

Background: Renal transplantation remains the treatment of choice for end-stage renal disease (ESRD) in regard to patient survival. Factors known to influence long-term graft survival are recipient age, race, presence of diabetes, delayed graft function (DGF), HLA mismatching, and acute rejection episodes. Renal function within the 1st year of transplantation also has been reported to an important factor influencing graft survival. Aims of Study: (1) To study the influence of donor-related preoperative factors on early graft function. (2) To study the influence of matching-related preoperative factors on graft function. Methods: The study includes 50 pairs of live-related and -unrelated renal-allograft recipient and donors from 2011 to 2017. Cadaveric allograft recipients are excluded from the studied. Second renal allograft recipients are excluded from the studied. ABO-incompatible transplantations are excluded. Early graft function was assessed by serum creatinine estimation at 6 months after transplantation. The preoperative variables will be correlated with the early graft function using statistical methods. Results: On regression analysis, serum albumin and hemoglobin level of the recipient showed a significant negative correlation with level of serum creatinine at 6 months. Duration of dialysis before transplantation was associated with higher serum creatinine. However, the association was not statistically significant. Higher donor-to-recipient body surface area was associated with lower 6 month serum creatinine levels. Conclusion: Maintaining good nutritional status in hemodialsyis patients helps in lesser hospitalizations and better graft function when they are transplanted. Serum creatinine at the end of 6 months can be used to prognosticate long-term graft survival.


  Chylous Ascites: A Rare Complication of Laparoscopic Donor Nephrectomy – Case Report and Review of Literature Top


Abhinav Seth, Ashish Sharma, Deepesh Benjamine Kenwar, Sarbpreet Singh, Gaurav Shankar Pandey, Vidyasagar Kallepalli

Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drabhinavseth@gmail.com

Background: Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay, morbidity in postoperative period, and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively, but surgical intervention may be occasionally required. This report describes importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment. Aims of Study: To discuss the management of CA which is a rare but significant complication of LDN. Methods: A comprehensive review of literature regarding this rare complication after LDN was performed with PubMed/Medline and Google Scholar using “chyle, complications, laparoscopic donor nephrectomy” as keywords. The demographic profile and management of patients are discussed in detail. The various surgical modalities used to manage these patients are described. Results: Fifty-five cases of chyle leak/CA have been reported after LDN in literature till date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parentral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application, use of argon coagulation, endosuturing with application of glue after 36.1 ± 19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6-month follow-up. Conclusion: CA is a rare complication after donor nephrectomy in experienced centers. While conservative management remains the first line of treatment, early surgical treatment shall be undertaken in cases of massive ascites.


  Sociodemographic and Clinical Profile of Posttransplant Erythrocytosis Top


Chinmaye Sapre, K. Praveen Kumar Kolla, Varaprasad Rao, Raghavendra Sadineni

Narayana Medical College, Nellore, Andhra Pradesh, India. E-mail: chinmayesapre16@gmail.com

Background: Posttransplant erythrocytosis (PTE) is defined as a hematocrit persistently above 51% after a renal transplant. The incidence of PTE is 10%–15%. It is most commonly seen after 8–24 months after transplant. Aims of Study: to find the association of pretransplant factors in development of postrenal transplant erythrocytosis. Methods: This is a retrospective descriptive study. Patients undergoing transplant had their baseline characteristics evaluated at the time of the transplant. These patients were screened and patients fitting the inclusion criteria were included in the study. These cases were matched with controls with similar baseline characteristics. Univariate regression analysis was used to find correlation of different factors associated with PTE. Result: A total of 84 transplants were done of which seven patients developed PTE (incidence = 8.3%). Out of the seven transplants, five were live-related transplants and two were deceased donor transplant. The statistically significant pretransplant factors associated with PTE were presence of smoking, pretransplant iron, and erythropoietin supplementation (P < 0.05). The presence of HTN, native kidney in situ, and pretransplant duration of hemodialysis were all found to be associated with PTE but were not statistically significant. Testosterone levels in patients with PTE showed no elevation. No patient in the PTE was found to have renal artery stenosis. Two patients PTE reverted spontaneously and two patients PTE subsided after starting angiotensin converting enzyme inhibitor. Three patients needed phelobotomy as they did not respond to pharmacological treatment. Conclusion: PTE is an uncommon complication seen postrenal transplant. Factors predictive of PTE are pretransplant presence of smoking, erythropoietin supplementation, and iron supplementation.


  CYP3A5 Genetic Polymorphisms in Renal-Transplant Recipient Patients and Its Relation with Tacrolimus Dosing and Complications: A Retrospective Study from a Tertiary Center in South India Top


Anvesh Golla, Sreebhushan Raju, Krishna Prasad, Sonu Manuel

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Background: Tacrolimus is the most commonly used immunosuppressant in kidney-transplant patients. It provides better allograft survival and lower incidence of nephrotoxicity compared with cyclosporine. The variable pharmacokinetics of tacrolimus has impact on optimal management of kidney-transplant patients. This variability has been attributed to the genetic polymorphism of CYP3A5. We study the effect of CYP3A5 polymorphism, its impact on infections, acute rejection, and acute tacrolimus-related nephrotoxicity. Aims of Study: To study the CYP3A5 genetic polymorphism in renal-transplant recipients and its association with tacrolimus dosing and complications. Methods: This is a retrospective study done over a period of 2 years (2016–2018) from a tertiary center in South India. A total of 152 patients were recruited and genetic polymorphism in CYP3A5 enzyme expression was studied by Sanger's sequence-based genotype. Accordingly, patients were divided into wild variant (CYP3A5-AA) where there is full expression of the enzyme, heterozygous (CYP3A5-AG), homozygous group who were nonexpressors (CYP3A5-GG). Day 0 and day 5 tacrolimus concentrations and tacrolimus concentration/drug (C/D) ratio were measured. Tacrolimus-related toxicity, infections, and rejections were analyzed and the serum creatinine at the time of discharge was compared among the groups. Result: Out of 152 renal-transplant recipients, male-female ratio was 3:1 with a mean age of 37 ± 9.8. Deceased donor renal transplants were 37 and live donor renal transplants in 115 patients. Immediate graft function was seen in 117 (76%) patients. Tacrolimus C/D ratio was less in AA variety compared to both AG (0.006) and GG (P < 0. 00001). Tacrolimus toxicity was noted in 28 (18%) patients, of which ATN 24 (85%), TMA 3 (11%), and pancreatitis and pulmonary edema 1 each (3.5%). None of the above complications were noted in the wild group. Most common infectious complication was urinary tract infections seen in 22 (14%) patients: AA – 3 (10%), AG – 9 (14%), GG – 10 (16.7%). CMV disease was noted in 13 (8%) patients: AA – 3 (23%), AG – 8 (61%), GG – 2 (15%). Sepsis was seen in 11(7%) patients: AA – 2 (7%), AG – 4 (6%), GG – 5 (8%). NODAT was seen in 10 (6.5%) patients: AA – 1 (3%), AG – 2 (3%), GG – 6 (10%). ABMR were seen in five patients: AA – 2 (7%), AG – 2 (3%), GG – 1 (1.6%). Mean serum creatinine at the time of discharge was significant between the groups. Conclusion: Genetic polymorphism of CYP3A5 effects the tacrolimus dose requirement. AA is associated with low C/D ratio; AG and GG are at higher risk of developing nephrotoxicity and infections. Tacrolimus-related complications can be predicted before renal transplant, which leads to better graft and patient survival.


  The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis Top


Ankur Sharma, Akhil Dhanesh Goel, Prem Prakash Sharma, Varuna Vyas, Sumita Agrawal

All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. E-mail: ankuranaesthesia@gmail.com

Background: Adequate analgesia for patients undergoing liver transplant (LT) surgeries is a major challenge for the transplant teams. Aims of Study: We undertook this meta-analysis to consolidate the available evidence and to quantify the analgesic potential/opioid sparing capability of TAP block in patients undergoing liver transplant surgeries. Method: We used a population, intervention, control, and outcome study (PICOS) format for the identification of the potential trials that could be included in the present meta-analysis. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgery (donors) were included as the primary outcome in the analysis. Search strategyThe preliminary data search was performed by two independent researchers in Cochrane Central Register of Controlled Trials and PubMed. Comparative trials published until April , 2018 were included in the analysis. Result: Results: There were a total of 627 articles regarding TAP Block in PubMed and 405 in Cochrane database of which a total of 6 articles were about comparative assessment in liver transplant patients. 2 articles were in duplicate thus giving 4 eligible articles whose full texts were read for inclusion in systematic review. Pooled effect size by random effects model showed that TAP group had 27.59 mg (95% CI: 33.47 – 21.70) lower requirement of morphine at 24 h for pain mitigation. It also showed that TAP group had less PONV. Conclusion: Conclusions: TAP-block significantly lowers the cumulative postoperative 24-h opioid consumption and PONV in LT donors and recipients. The technique of the block needs standardization for patients undergoing LT surgeries.


  Association of NK-Cells and Receptor NKG2A with Anti-HLA Antibodies in Renal-Transplant Recipients Top


Kesiraju Sailaja, Kesiraju Sailaja1, D. K. Prudhula2, V. Vijayalakshmi2, R. Vankayalapati3, C. H. Umamaheswararao4, V. S Reddy4, S. Sahariah4

Transimmune, 1Transplantation Immunology and Research Centre, 2Mahavir Hospital and Research Centre, Hyderabad, Telangana, 4Krishna Institute of Medical Sciences, Karad, Maharashtra, India, 3The University of Texas Health Center, TX, USA. E-mail: kesirajusailaja@gmail.com

Background: One of the major challenges in solid organ transplantation is rejection of the allograft. Antibody-mediated rejection (ABMR) caused by anti-HLA antibodies is associated with graft loss, and there are limited treatment options either to prevent/reverse ABMR. HLA-specific alloantibodies may trigger NK-cell activation to mediate antibody-dependent cell-mediated cytotoxicity (ADCC) causing microvascular damage leading to humoral rejection. Aims of Study: The present study aimed to evaluate the distribution of NK-cell subsets and its inhibitory receptor in renal-transplant recipients with anti-HLA antibodies. Methods: Pre- and post-transplant blood samples were collected from 62 renal-transplant recipients. Biopsies were performed in 41 patients. Blood samples were collected before the biopsy in these patients. Posttransplant serum samples were analyzed for anti-HLA antibodies and NK-cell subsets were monitored in the peripheral blood mononuclear cells. Expression of NKG2A was assessed in pre- and post-transplant samples in CD56 dim, CD56 bright, and CD8 dim and bright T-cells. Serum creatinine, MDRD-4-eGFR, and urinary protein/creatinine ratio were measured. Data of immunosuppressive therapy were collected. Results: Out of 62 recipients, 17 patients were detected with donor-specific anti-HLA antibodies (DSAs), 6 were non-DSAs, 23 were without HLA antibodies, and 16 recipients with chronic allograft nephropathy (CAN) whose serum creatinine was >1.9 mg/dl. We noticed that there was a decrease in the percentage of NK-cells immediately after transplant when compared to pretransplant (5.89 ± 1.24 vs. 2.04 ± 0.87). The absolute number of NK-cells was significantly reduced in DSA-positive patients. Higher percentage of CD56 bright and lower percentage of CD56 dim were observed in DSA-positive recipients compared to patients without antibodies. Both DSA-positive and non-DSA patients showed increased NKG2A+ NK-cells, suggesting the stimulation of NK-cells by the undetectable antibodies present on the graft endothelium. There was a marked increase in NKG2A expression CD56 dim subset at the time of acute allograft rejection. Higher percentage of CD56 dim NKG2Acells was observed in CAN patients signifying that anti-HLA may selectively influence the NK-cell subsets. There was no correlation between C4d deposits and NK-cell subset profile among these patients. A correlation between serum creatinine and NKG2A cells (r2 = 0.62; P = 0.03) and eGFR MDRD (r2 = −0.47, P = 0.05) in patients with anti-HLA antibodies was observed. Conclusion: The altered distribution of NK-cell subsets may be associated with an increased alloantibody turnover. Increased expression of NK-cell receptors may induce cytotoxicity and cytolytic effector functions leading to ADCC. Assessment of NK-cell subsets might be used as biomarker for predicting ABMR.


  Anesthetic Agent-Induced Renal-Allograft Dysfunction Top


Gaurav Vohra, Manish Rathi, H. S. Kohli, K. L. Gupta

Department of Nephrology, PGIMER, Chandigarh, India. E-mail: cooldoc1978@rediffmail.com

Background: One of the varied adverse effects of halogen-based anesthetic agents is malignant hyperthermia. Although a comparatively safer anesthetic agent, isoflurane has been known to induce this peculiar effect in patients with compromised liver, heart, and particularly brain. Aims of Study: NA. Method: NA. Diagnosis is primarily based on clinical signs (10 C/h rise in body temperature, tachycardia, tachypnea, rise in creatinine kinase levels, serum cholinesterase levels, derangements in red blood cells, white blood cells, and platelets), presence of myoglobinuria, and organ biopsy, in case of organ failure. Result: NA. We present the case of a 38-year-old gentleman with end-stage renal disease on maintenance hemodialysis since 2010 and no previous history of allergy/reaction to anesthesia. He was posted for ABO-compatible live-related renal allograft transplant, induced with isoflurane and succinylcholine; the patient developed tachycardia, tachypnea, hyperthermia, hematemesis, and bleeding from epidural site. Conclusion: Managed with paracetamol infusion, patient had urine output of 1.3 L immediate postoperative with creatinine of 8.0 mg/dL on postoperative day 2. Although the patient had normal evaluation except raised creatinine kinase, renal biopsy showed pigment cast nephropathy.


  Evaluation of Health System Cost for Transplant Care in a Tertiary Care Center Top


Bhaskar Krishnamurthy, Smita Pattanaik, Shankar Prinja, Deepesh Kenwar, Ashish Sharma

Post-Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drbhaskar.pgi@gmail.com

Background: Renal transplantation is a means of treating end-stage renal disease (ESRD). However, the costs borne by a health service provider such as a tertiary care hospital to provide these services has not been determined. It remains to be seen how much money the hospital needs to invest to provide transplant services and under what headings. Aims of Study: To determine the cost borne by a tertiary care center (PGIMER, Chandigarh) to provide health care to patients undergoing renal transplantation. Methods: Bottom-up costing methodology was employed to collect data on health system costs. The health service centers for renal transplantation included renal transplant operation theater (OT), renal transplant intensive care unit (ICU), inpatient department (IPD), outpatient department, and hemodialysis (HD) unit. The transplant ICU and OT cater exclusively to the transplant patients. However, the OPD, IPD, and HD units cater to other patients as well; hence, costs were appropriately apportioned based on the patient load. The costs incurred were grouped under various subheadings such as capital expenditure, workforce, and other consumables which included medicines, surgical items, sanitary equipment, and stationery equipment. In addition, out-of-pocket (OOP) expenditure for each patient was also determined. Result: We observed that a significantly high expenditure is borne by the hospital in providing health care to renal-transplant recipients. In addition, the OOP expenditure by the patients on medicines, diagnostic tests, hospitalization, and other nonmedical expenses were also calculated to be INR 32,904 per patient, out of which a significant chunk was incurred on procuring medicines. Conclusion: The health service provider expenditure to provide renal-transplant services in a tertiary care center can be broadly classified into capital and recurring. Among the recurring expenses, the majority is spent on workforce, i.e., human resources involved in patient care.


  Spectrum of Infections in Kidney-Transplant Recipients with rATG Induction Top


Narinder Sharma, Manoj Kumar Singhal, Dushyant Nadar, Anuja Porwal

Fortis Hospital, Noida, Uttar Pradesh, India. E-mail: drnarinderpunj@gmail.com

Background: Infections account for significant morbidity and mortality after kidney transplant. There is an increase in the use of rATG induction in kidney-transplant recipients worldwide, as well as in India. This study aims to look at the spectrum of infections in kidney-transplant recipients with rATG induction. Aims of Study: To study the spectrum of infections in kidney-transplant recipients with rATG induction. Methods: A total 109 consecutive kidney-transplant recipients enrolled between June 1, 2015, and May 31, 2017, and followed till May 31, 2018. 102 (94%) patients received rATG. Patients with high risk were given high-dose rATG (>4.5 mg/kg/day). Rest all patients were offered low-dose rATG (<4.5 mg/kg, usually 3 mg/kg). All patients received CNI, MMF, and steroids. CNI was started on dose of 0.1 mg/kg/day and titrated as per trough blood levels. MMF was started on initial dose of 1 g twice a day, tapered to 500 mg thrice a day on the postoperative day 8. Steroids were started at dose of 40 mg once a day and were reduced to 5 mg once a day by postoperative 2 months. Trimethoprim/sulfamethoxazole (80 mg/400 mg) was given for pneumocystis carinii pneumonia prophylaxis for minimum of 6 months. CMV prophylaxis was given to patients with high risk (high-dose rATG, i.e., >4.5 mg/kg/day, D+R−). Detailed assessment for infections and clinical profile was done during each follow-up visit. Data were tabulated and statistically evaluated. Results: Mean follow-up period was 1.2 ± 0.8 years. Forty-two episodes of infections were recorded in 35 patients (32%). Mean period to first infectious episode was 7.25 ± 6.56 months. Of all infectious episodes, 21% were in initial 1st month, 38% were in 2nd–6th month, and 41% were after 6 months. Nine percent of all patients had urinary tract infections. Gastrointestinal infections were recorded in 7% patients, lung infection in 5% patients, soft tissue infections in 5%, and sepsis in 3% patients. Five percent patients had herpes zoster, 3% patients had CMV infection. Other infections were recorded in 3% patients. Bacterial infections constituted 62% of all infectious episodes. 24% of all infectious episodes were virus related and 9% of all infections were fungal. A total of three deaths were recorded in the study, all deaths were due to infections. Death-censored graft survival was 97.6% at the end of 1 year. Patient survival was 97.78% at 1 year. Conclusion: We found that despite using rATG in most of our patients, the overall rate of infection in our study was low and is comparable to other studies. Hence, we concluded that the overall net immunosuppression rather than the use of specific induction agent is the harbinger of infection.


  Complex Vascular Anatomy in Retroperitoneoscopic Donor Nephrectomy Top


Bipin Chandra Pal, P. R. Modi, S. J. Rizvi

Institutions: Institute of Kidney Diseases and Research Centre, Institute of Transplantation Sciences, Ahmedabad, Gujarat, India. E-mail: bipjip@gmail.com

Background: Donor nephrectomy is a challenging surgery as it deals with a normal person. Simple vascular anatomy is considered while performing laparoscopic donor nephrectomy. However, complex vascular anatomy poses a major challenge to the donor surgeon. Aims of Study: To assess the safety and efficacy of retroperitoneoscopic donor nephrectomy in donors having complex vascular anatomy. Methods: Data of 1520 donors who underwent retroperitoneoscopic donor nephrectomy between September 2004 and December 2017 were retrospectively analyzed, and parameters of OT, WIT, blood loss, and complications were studied in them. Results: Mean age of the donors was 48.5 ± 10.5 years. Mean body mass index was 23.61 ± 4.76 kg/m2. Multiple arteries were observed in 216 donors. Multiple veins were observed in 66 donors. Mean OT (min) was 132.62 ± 59.47 and 225.20 ± 85.28, respectively, in donor having single versus multiple arteries. Mean WIT (s) was 178.58 ± 67.7 and 225.20 ± 85.28 between the two groups. Mean OT (min) was 133.70 ± 59.99 and 141.08 ± 49.35 in single versus multiple veins. Mean WIT (s) was 182.56 ± 71.14 and 250.65 ± 73.73, respectively, in the two groups. Statistically significant difference was observed for OT and WIT in single versus multiple arteries while only for WIT in single versus multiple veins. Conclusion: Laparoscopic donor nephrectomy is safe in donors with complex vasculature in experienced hands. It helps increase the donor pool.


  Back Table Preparation of Pancreas Allograft: Video Top


S. J. Rizvi, B. C. Pal, S. Kumar, P. R. Modi

Institute of Kidney Diseases and Research Centre and Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India. E-mail: hoblingoblin@yahoo.com

Background: Transplantation of the whole pancreas offers long-term euglycemia and possible reduction in end-organ damage due to diabetes. Pancreas transplant is technically challenging and requires attention to detail and meticulous surgical technique. Back table preparation is an important part of ensuring good surgical outcomes. Aims of Study: The aim of this video is to demonstrate the steps of back table preparation in a systematic manner. Methods: We hereby present an edited video showing the steps of back table preparation of a pancreas allograft retrieved from a deceased donor. Steps shown include removal of the spleen and control of the splenic vessels, trimming of the upper and lower edges of the pancreas, over-running of the duodenal ends, stapling and control of the mesenteric root and mesocolon, ligation of ganglion tissue, creation of the iliac artery conduit, and final hemostasis. Results: At the end of bench preparation, the allograft should have good flow in the superior mesenteric and splenic arteries with no significant bleeding and secure duodenal ends. Conclusion: Meticulous bench surgery is essential for good surgical outcomes of pancreas transplant. This video shows the critical steps of back table preparation.


  Postrenal Transplant Viral Infections: A Single-Center Observational Study Top


U. Avinash Rao, Abhijit Konnur

Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India. E-mail: dr. avinashrao1@gmail.com

Background: Viral complications posttransplant are associated with different risks of morbidity and therefore need to be clearly defined. In this study, we have analyzed the incidence, prevalence, complications, and factors influencing posttransplant viral infections at our center. Aims of Study: To study the incidence and prevalence of viral infections in live renal-transplant patients at our center. Methods: It is a prospective longitudinal observational study of 6 months duration. A total number of 96 live-related renal transplant patients were included. Among them, 58 have completed 6-month follow-up, 28 have completed 3-month follow-up, and remaining have completed 1-month follow-up. Viral profiles were done at pretransplant period, 1, 3 and 6 months as well as when indicated necessary during follow-up. Results: Among the different viruses studied, the incidence of cytomegalovirus (CMV) was 2.2% pretransplant, 4.2% at 1st month, 1.2% at 3rd month, and 29.3% at 6th month and of BK virus (BKV) was 1% pretransplant, 1.1% at 1st month, 1.2% at 3rd month and 5.6% at 6th month. The prevalence of CMV is 7.3% and BKV is 6.3%. Two of the patients had CMV syndrome have been treated timely. None other infection was detected. Conclusion: The data have practical relevance highlighting the need for mandatory testing of recipients' serostatus with regard to certain viral infections (CMV and BKV) to assess the risk of posttransplant viral complications and provide adequate antiviral prophylaxis and treatment strategy.


  Infectious Complications after Rituximab Therapy in Kidney-Transplant Recipients Top


Prashant Rajput, Pavan Deore, Zaheer Virani, Hepal Vora, Hitesh Gulhane, Ishan Pariekh, Bharat Shah

Institute of Renal Sciences, Global Hospital, Mumbai, Maharashtra, India. E-mail: drprashantr@yahoo.com

Background: Off-label use of rituximab is increasing in kidney transplantation. We reviewed the occurrence of infectious complications and its outcome after rituximab therapy. Aims of Study: To compare the infectious complications in kidney-transplant recipients who received rituximab and those who did not. Methods: We included all patients who underwent kidney transplant between February 2012 and June 2018 who received rituximab (200–500 mg, 1 or 2 divided doses) as an induction agent. We reviewed the occurrence of infectious complications and its outcome in those who received rituximab and compared with a control group who did not receive rituximab. Results: The study included 351 patients between January 2012 and June 2018; 140 (39.8%) were in rituximab group and 211 (60.2%) in control group did not receive rituximab. The median follow-up was 37.4 months for rituximab group and 28 months for control group. The incidence of infections was significantly higher in rituximab group (78.5% vs. 40.9%, P = 0.00005). The incidence of bacterial infection (P = 0.004) and tuberculosis (P = 0.048) was significantly high in rituximab group. Eighteen out of 140 patients (12.8%) died in rituximab group, of which 10 deaths (7.1%) were due to an infectious cause, compared to 4.7% in the control group(P = 0.005). The independent predictive factors for infection induced death were the combined use of rituximab and antithymocyte globulin, diabetes mellitus, age >60 years, and bacterial and fungal infections. Conclusion: The use of rituximab is associated with a higher risk of infectious complications and death in kidney-transplant recipients.


  Incidence of Antibody-Mediated Rejection and Its Outcomes in Renal-Transplant Patients: Single-Center Experience Top


Navin Pattanashetti, Raja Ramachandran, Ashish Sharma, Ritambhra Nada, K. L. Gupta

Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: navishetty42@gmail.com

Background: Kidney transplantation is the best option for end-stage renal failure. An immune response that develops against alloantigen leads to the destruction of the transplanted organ and remains the first cause of renal allograft failure. Rejection involves cellular and antibody-mediated rejection (ABMR). ABMR is currently considered as the leading cause of early and late graft failure. Aims of Study: To assess the incidence and treatment outcomes of ABMR in resource-poor setting. Method: It is a prospective observational study carried from July 2016 to December 2017, which included all patients who underwent renal transplant during recruitment period of 8 months (July 2016 to February 2017); then, they followed up for 9 months to assess the incidence of ABMR, response to therapy, and various outcomes following therapy. Outcomes noted were improvement in allograft function, chronic graft dysfunction, and graft loss. Result: A total of 122 patients included, all underwent only CDC cross match, FXM done in patients with prior transplant. 27 (22.3%) had acute ABMR, 24 (88.8%) had within 1 month, and 3 (11.2%) from 1 to 3 months after transplantation. There were 23 (85.2%) males and 4 (14.8%) females. The mean age was 35.67 ± 9.67 years, 85.2% were from low socioeconomic status. Basic disease, unknown in 44.4%, 15 (55.6%) related donor, 7 (25.9%) deceased donor, 5 (18.5%) spousal donor, history of blood transfusion 21 (77.8%). Induction was 9(33.3%), 2 (7.4%) and 16 (59.3%) with ATG, basiliximab, and no induction, respectively. C4d negativity was observed in 19(70.37%). All received 3 days pulse steroid following rejection episode and standard therapy was continued, none received IVIg or PLEX due to financial constraints. Graft function improved in 10 (37%), 15 (55.6%) developed chronic graft dysfunction, and 2 (7.4%) developed graft loss. On multivariate analysis, history of blood transfusion was statically significant between ABMR and non-ABMR groups (77.8% vs. 29.8% P = 0.001). Conclusion: The incidence of ABMR in one-fifth, history of blood transfusion is the important predisposing factor for ABMR. It is necessary to have detailed immunological workup and adequate treatment for ABMR to improve the outcomes even in resource-poor setting.


  Right Retroperitoneal Laparoscopic Living Donor Nephrectomy: A Single-Center Experience of 200 Consecutive Cases Top


Forqan B. Shaikh, D. S. Ray, T. K. Saha, S. K. Bajoria

NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India. E-mail: forqanbs@gmail.com

Background: Retroperitoneal laparoscopic donor nephrectomy (RPLDN) has gradually become the main approach to obtain the live donor kidneys. These techniques are considered less invasive for the donor, allowing lower postoperative analgesic requirements and faster return to daily activities. However, the shorter right renal vein limits its wider application. Aims of Study: To evaluate the feasibility and safety of right-sided retroperitoneal laparoscopic live donor nephrectomy. Methods: Between July 2014 and July 2018, a total of 1700 living donors underwent consecutive three-port retroperitoneal laparoscopic donor nephrectomies out of which 200 underwent right-sided nephrectomies. The initial retroperitoneal space was created by insertion of a catheter attached to a saline-filled mid-finger of a glove. The renal hilum and ureter were circumferentially mobilized. The ureter was sheared with scissors. The main renal artery was controlled, using 2 Hem-o-lok clips placed at proximal end. In initial 100 cases, we used single XL Hem-o-lok clip later on we started using Endo-TA stapler with 30 mm articulating reload which is applied on the IVC to get a cuff of IVC along the right renal vein stump. The graft retrieved through the inguinal incision. Results: All the 200 right RPLDNs were carried out successfully. The average operation time and mean warm ischemic time were 74 and 4 min, respectively. The average blood loss was 80 ml. No blood transfusion or open conversion was required. No major complication occurred in the donors and donors were discharge after an average of 4 days. Among the 200 right RPLDN, 48 patients had two renal arteries. Twenty patients had early branching of the main renal artery (1.0–1.5 cm from the aorta). In initial 100 cases, we used single XL Hem-o-lok clip later on we started using Endo-TA stapler with 30 mm articulating reload was applied on the IVC to get a cuff of IVC along the right renal vein stump. Anatomically, the right renal vein is short and thin walled to overcome this anatomical challenge associated with right RPLDN. Grafts with short renal vein were tackled by placing the kidney upside down during transplantation. We have not encountered the need for any back table surgery on the right-sided kidney grafts. Conclusion: Right-sided retroperitoneal laparoscopic donor nephrectomy is safe even in patients with a complex vascular anatomy with no added morbidity and less operative time. The modified approach of retroperitoneal laparoscopic donor nephrectomy could be a cost-effective and safe alternative.


  Partial Immunological Tolerance Induction with Extracorporeal Photopheresis in Renal Transplantation Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Alexander Kildushevsky, Alexander Faenko, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Extracorporeal photopheresis (ECP) is an effective method of resistant transplant rejection management. This method is widely used in renal, heart, and lung transplantation. In terms of renal-transplant rejection prevention, this method and its mechanism of action are not studied well enough. Aims of Study: To study both the mechanism of action of ECP and its influence on frequency of rejection episodes and renal-transplant function. Methods: Materials and Methods: A prospective randomized cohort study in 30 pairs of recipients has been conducted. One donor kidney was transplanted to a patient of the main group, the other – to the patient of the control group. The main group patients were treated with 15 sessions of ECP. A percent (%) of naive T-helpers expressing CD28 (CD3+CD4+CD27+CD28+CD45RO – phenotype) and mean fluorescence index (MFI) of the molecule were investigated. Results: In healthy people CD28 is present on the whole surface of naive T-helpers pool. In recipients of renal transplant on 4th day after transplantation, CD28+ Th and MFI decrease significantly – P < 0.001. In the main group on 30th day, a significant decrease in percentage of CD28+ Th (P < 0.001) and MFI (P < 0.001) was observed in relation to the parameters on 4th day after transplantation. This dynamics in patients of the main group can be indicative of a specific and universal inhibition of expression of coactivating molecules on naive T-helpers. Patients in the control group on the 30th day after transplantation had no significant changes in percent of T-helpers expressing CD28 (P = 0.42) and MFI (P = 0.087). The number of CD28+ Th in patients of the main group was statistically different from that of control group (P < 0.001). Furthermore, in the main group, the number of CD8 cells on 30th day was significantly lower than that on 4th day (P = 0.02), as well as in control group (P < 0.001). Conclusion: ECP may be an inductor of partial immunological tolerance to transplant. The study assessing long-term outcomes is in progress.


  Broad Antigen Mismatches and Epitope Mismatches in Kidney Transplantation Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Selection using epitope mismatches (EpMM) has good potential in recipients with pre-existing antibodies and also in kidney allocation in network of transplant centers with a large common waiting list. Is the use of EpMM advantageous compared to the use of broad-antigen mismatches in a single transplant center? Aims of Study: We have analyzed the link between the risk of losing a transplant and EpMM and broad-antigen mismatches. Methods: The results of 347 recipients who had a first cadaveric kidney transplant were analyzed. The recipients did not have any pre-existing antibodies. HLA-genotyping of recipients was performed using the sequence specific primers method. Results: The five-year survival rate decreased as the number of broad-antigen mismatches increased (log rank P < 0.001). Univariate analysis showed a higher number of HLA-A, -B, -D, and -DR mismatches to be associated with an increased risk of transplant loss (P = 0.015, P = 0.001, P < 0.0001). Results: However, multivariate adjusted Cox proportional hazard regression showed HLA-B and -DR mismatches (P = 0.001, P < 0.0001) to be associated with higher risk, but not the HLA-A (P = 0.146). There was a linear relationship between the number of broad-antigen mismatches and the risk of transplant loss. Increased EpMMs were exponentially, not linearly related to the risk of transplant loss. Nevertheless, the number of EpMM remains a risk factor, even when adjusted for the number of broad-antigen mismatches in the multivariate analysis (P < 0.001). EpMM allows for more accurate prediction of the risk of transplant loss: the area under the receive operating characteristic curve was 0.812 (0.766, 0.858) versus 0.649 (0.59, 0.707) in broad-antigen mismatches. This approach allows to identify patients at high risk of transplant loss (over 20 EpMM) among patients, who were previously considered to have low immunological risk (i.e., 1–2 broad mismatches). Conclusion: In routine practice of a single transplant center with a small waiting list, the use of epitope mismatches may be beneficial. It will allow choose the optimal option – the minimal number of epitope mismatches among a few potential recipients with the equal numbers of broad-antigen mismatches.


  Pioneer of Transplantology-Vladimir Demikhov: Too Incredible for Reality, Too Real for Fantasy Top


Aleksei Zulkarnaev, Andrey Vatazin

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: 20th century is the era of origin and incredibly fast development of transplantation as a science and as a branch of medicine. Moreover, if the author of the first transplantation of a cadaveric kidney in 1933 is Y. Y. Voronoy that got a worldwide recognition, the merits of another transplantation pioneer, V. P. Demikhov, are much less known. Aims of Study: Moreover, at the same time, to overestimate Demikhov's contribution in modern transplantation and cardiovascular surgery is impossible. Methods: In 1937, being a third-year student, he designed and produced the world's first artificial heart and implanted it in his dog himself. The dog was alive for 5 h. This daring researcher carried out the following operations for the first time in the world (as an experiment): 1937 – successfully implanted an artificial heart, 1946 – a heterotopic heart transplantation into a chest cavity, 1946 – a coupled transplantation of a heart–lung complex, 1947 – single lung transplantation, 1948 – liver transplantation, 1951 – orthotopic heart transplantation without the use of cardiopulmonary bypass, 1952 – mammary coronary artery bypass, 1954 – the transplantation of the second head to a dog. Results: In 1965, Demikhov developed the method of maintaining the vital organs by their xenotransplantation. As a result, four cardiopulmonary complexes were transplanted into one animal and they were functioning within 7 days. It is striking that despite the fact that Demikhov had a remarkable surgical technique, he was not even a doctor and he was a biologist. Christian Barnard who performed the world's first heart transplant from a human into a human in 1967 came to the Demikhov's laboratory twice in 1960 and 1963. All his life Christian Barnard considered Demikhov as his teacher. Conclusion: V. P. Demikhov was far ahead of his time. Perhaps, partly because of this, he did not become widely known. His bold experiments seem fantastic even today. This great scientist takes place of honor among the pioneers of the world transplantation.


  Renal Transplantation Outcomes in Average-Sensitized Recipients Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Antibody-mediated graft rejection is the most severe form, which often leads to graft loss. We applied double-filtration plasmapheresis (DFPP) in the early postoperative period in average-sensitized recipients. Aims of Study: To compare the efficacy of two desensitization protocols: DFPP with low intravenous immunoglobulin (IVIG) dose versus high-dose IVIG only. Methods: This prospective cohort study included 42 patients with C4d+ ABMR. Patients of study group received DFPP with low-dose of IVIG (100 mg/kg), patients of control group received high-dose IVIG (2 g/kg) only. Desensitization started on the day of transplantation. Each recipient had 4–5 treatments. The study group includes 19 patients with average PRA 25.1% ± 6.1%. Control group includes 23 patients with PRA 18.9 ± 4.4. Crossmatch was negative in both groups. Results: Six episodes of acute rejection and one episode of infection were registered in the study group; 13 episodes and three episodes were in the control group, respectively. Acute rejection caused total loss of graft function in four patients of study group and in eight patients of control group. In the study group, overall renal graft survival was 79%. It was 65% in the control group. Annual graft survival consists 94% and 62%, respectively. Results: Graft function was significantly better in the study group. At 3 months after transplantation, patients of the study group had a significantly lower level of daily proteinuria (P < 0.001). At 6 months – higher GFR (P = 0.001) and lower daily proteinuria (P = 0.01) were observed. At 1 year after transplantation, patients of the study group had lower creatinine plasma level (P = 0.001), higher GFR (P = 0.001), lower daily proteinuria (P = 0.001) versus patients of control group. Our study showed that increasing of acute rejection episodes and graft survival rate can be observed also in low-sensitized recipients. Graft survival is higher in the study group. Conclusion: Thus, DFPP with low-dose IVIG is more effective treatment compared to high IVIG dose regimen. It also has a beneficial effect on anti-HLA donor-specific antibodies production de novo.


  Treatment of Sepsis after Renal Transplantation with Endotoxin Adsorption Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Sorption of endotoxin is an effective method of treatment of sepsis. However, the experience with this method is very small in kidney transplantation. Aims of Study: We studied the effect of endotoxin adsorption on renal graft function in Gram-negative or mixed infections. Methods: The procedures were performed using extracorporeal hemoperfusion cartridge Toraymyxin PMX-20R (Toray, Japan) or LPS Adsorber (Lund, Sweden). We compared the outcomes of the main group, numbering 28 patients, with a comparison group, numbering 25 patients. In all patients of the main group, we applied the selective endotoxin adsorption. All patients were diagnosed with Gram-negative or mixed sepsis with different etiology. Results: Usually, in both groups, urine output was significantly reduced. There was observed an increase of daily diuresis, mainly, we believe, as a result of adequate fluid resuscitation. The differences between the groups were not significant. The dynamics of diuresis in patients of the main group was more physiological. Results: Creatinine clearance graft function has more injured than excretion of fluid. In most patients, a marked increase in serum creatinine was observed. Patients of the main group showed a strong trend to normalization of azotemia after 1 or 2 days of treatment, when sessions of endotoxin adsorption were performed. Thus, the decrease of serum creatinine in the main group was more expressed and significantly different from the comparison group of patients who have not had the adsorption of endotoxin. Glomerular filtration rate were also significantly improved in main group patients. Resistivity index in patients of comparison group was assessed not as detailed as in the main group and it cannot compare the groups properly. However, it was found that in the result of generalized infection, there was an increase in resistivity index. As a result of the therapy and endotoxin adsorption, a significant decrease of this index was showed. Conclusion: We observed a better survival in recipients of the main group. This was better showed in the later stages of treatment. However, in the case of multiple organ failure in both groups the mortality was 100%.


  Analysis of Bacterial Profile of the Transplantation and Dialysis Center: Nineteen-Year Report Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Empirical antibiotic therapy should be based on the frequency of occurrence of various bacteria. As practice shows, the microbial spectrum can vary greatly in time. Aims of Study: To analyze the microflora of the transplantation and dialysis center. Methods: We have examined the bacteriological tests results of 1282 patients in 1998–2016. In all patients, bacteriological tests were performed because of suspected of infection. The total incidence of bacterial pathogens in culture of blood, sputum, urine, and wound discharge increased from 61% to 76%. The part of Gram-positive bacteria monoculture has decreased (from 45% to 24%) and Gram-positive bacteria monoculture remained at the same level (37%–40%). At the same time, the frequency of the mixed flora is significantly increased (from 10% to 31%). In recent years, half of the microbial associations consisted of in 40% Gram-positive and Gram-negative bacteria, in 19% of Gram-positive and fungi, and in 19% of Gram-negative and fungi. In other cases, we observed ternary association. Thus, there has been a fundamental change in the nature of the microflora: the dominance of Gram-positive bacteria changed to Gram-negative, and the nature of the flora is usually mixed. Results: Gram-negative bacteria are the most common bacterial population in recent years. There are Klebsiella pneumonia (37%), Escherichia coli (28%), Pseudomonas aeruginosa (17%), Acinetobacter spp. (10%), Enterobacter spp. (8%). Enterococcus spp. (50%), Staphylococcus spp. (44%), and Streptococcus spp. (6%) found among Gram-positive bacteria. Fungi of the genus Candida were marked in 16% of culture: Candida albicans (40%) and Candida glabrata (30%) and Candida krusei (8%). Differentiation to the species level is not performed in 22%. The part of fungi in monoculture remained approximately at the same level (5%–8%). The incidence of C. glabrata and C. krusei increased. The most common Gram-positive bacteria have a high sensitivity to a number of antibiotics such as vancomycin and linezolid. We noted a growth of resistance of Klebsiella spp. even to modern antibiotics. Increasing of antibiotic resistance of E. coli was mentioned. Conclusion: Over the years, there was a great change in the nature and composition of the bacterial flora in patients of our center.


  Renal Transplant Ischemia/Reperfusion Injury Correction with Cytokines Adsorption Top


Aleksei Zulkarnaev, Andrey Vatazin, Dmitrii Artemov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Inadequacy of cellular metabolism in terms of hypoxia upon organ conservation leads to nephron injury. Cytokines play the leading role in pathogenesis of renal transplant ischemia/reperfusion injury. Aims of Study: To assess the effectiveness of cytokine adsorption in the correction of ischemic and reperfusion injury of the kidney transplant. Methods: We performed the prospective randomized clinical trial. We applied coupled plasma filtration and adsorption (CPFA) in 33 patients of study group. After the surgery, each patient had one procedure. In the control group, there were 33 patients who received paired transplants. All 66 transplants were received from expanded criteria donors. Results: Ischemia/reperfusion is followed by a significant release of cytokines (TNF, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, and p70) into blood that was observed in patients of control group. In addition to this, maximum peak was recorded 4–6 h after reperfusion. Moreover, a significant relation with conservation duration and thermal ischemia was observed. In patients of the study group, cytokine concentration remained stable. In patients of the main group, transplant function improvement was observed: a higher rate of diuresis and GFR, lower blood creatinine. CPFA has no effect on tacrolimus blood concentration. At 3 months after transplantation, patients of the main group had a significantly lower level of daily proteinuria (P > 0.001); at 6 months – higher GFR (P = 0.02) and lower daily proteinuria (P = 0.02), at 1 year after transplantation – lower creatinine plasma level (P = 0.001), higher GFR (P = 0.001), daily proteinuria being 2.5 times lower (P = 0.001) than patients of control group were observed. Conclusion: We believe that the selective removal of cytokines in the early postoperative period after kidney transplantation is an effective procedure and it may reduce the ischemia/reperfusion injury severity and improve outcomes with transplants received from expanded criteria donors.


  Changes in Pre-Existing Anti-HLA Antibodies and Kidney Transplantation Outcomes Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, India. E-mail: 7059899@gmail.com

Background: It is well known that lower panel-reactive antibody (PRA) score is associated with higher transplant survival rate. Sometimes, a fall in PRA at the point of transplantation (tx) compared to the peak value may lead to an underestimation of the risk. Aims of Study: To analyze the relationship between the peak PRAs (peak-PRA), value at the time of transplantation (Tx-PRA), and results of kidney Tx. Methods: The study included 287 patients from the waiting list with anti-HLA antibodies of I and/or II classes. A total of 142 patients underwent transplantation of a cadaveric kidney. All patients received standard immunosuppression: calcineurin inhibitor, mycophenolate, and steroids. Desensitization in the preoperative period was carried out in 11 patients. Screening and identification of antibodies were performed using multiplex technology on Luminex platform. The median PRA was 47% (IQR – 29%, 65%). The risk of rejection was assessed using Poisson regression. The risk of graft loss was assessed using Cox proportional hazard regression. Multivariate model was adjusted for sex and age of recipient, duration of dialysis, and number of HLA mismatches. Results: We identified four groups of patients: with stable, increasing, decreasing, or variable value of PRA. The change in PRA was accompanied by a change in the mean fluorescence index (MFI) (r = 0.787, r2 = 0.59, P < 0.0001). In the univariate analysis, each 5% of peak-PRA and Tx-PRA increased the incidence rate ratio (IRR) of ABMR (1.09 [95% confidence interval (CI) 1.06, 1.17], P < 0.001, 1.17 [1.09, 1.26], P < 0.001 respectively), and panel reactive antibodies decreased the IRR (0.932 [0.861, 0.967], P = 0.009). In adjusted multivariate model, we observed a similar scenario. In the univariate analysis, increases in peak-PRA and Tx-PRA increased the hazard ratio (HR) of graft loss (1.1 [1.05, 1.14], P < 0.001, 1.09 [1.05, 1.15], P < 0.001 respectively), and increase in Î"PRA decreased HR (0.952 [0.891, 0.97], P = 0.011). In the adjusted multivariate model, Tx-PRA did not increase a HR of graft loss (1.04 [0.95, 1.1], P = 0.098), while peak-PRA and Î"PRA remained significant factors (1.1 [1.17, 1.24], P < 0.001, 0.931 [0.855, 0.954], P = 0.007, respectively). Conclusion: In the selection donor-recipient pair, it is necessary to take into account the spectrum of antibodies at the point of peak values of PRA. A decrease in PRA may hide antibodies that have specificity to donor antigens or on certain epitopes.


  Therapeutic Plasma Exchange and Double-Filtration Plasmapheresis: Efficacy and Safety in the Treatment of Renal Graft Antibody-Mediated Rejection Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, India. E-mail: 7059899@gmail.com

Background: There are several methods of the rapid removal of antibodies from patient's plasma, among which are double-filtration plasmapheresis (DFPP) and therapeutic plasma exchange (TPE). Aims of Study: To perform a comparative assessment of efficiency and safety of DFPP and TPE. Methods: A prospective randomized cohort study in 58 recipients with renal graft antibody mediated rejection (C4d+) was conducted. Twenty-eight recipients received treatment with DFPP method, 32 – with TPE method. All patients received the same protocol of basic immunosuppression and anti-antibody-mediated rejection therapy. All patients underwent 3–4 sessions. The cumulative effect of complete course of procedures was investigated. Results: The decrease in IgG and IgM concentrations was significantly greater when using DFPP. When conducting DFPP, the loss of albumin was significantly lower (P = 0.01). When conducting DFPP, the plasma replacement was not required, while during TPE, abundant plasma replacement was necessary. As a result of abundant plasma replacement, international normalized ratio, activated partial thromboplastin time, fibrinogen remained within the normal range. At the same time, DFPP statistically significantly reduced the levels of fibrinogen concentration (P = 0.01). Both TPE and DFPP reduce the C0 of tacrolimus about 15%–20%. In this regard, the correction of drug doses is required. Rebound effect was observed when conducting DFPP, if <100% of volume of circulating plasma was processed during one procedure and <70% of volume of circulating plasma were removed during conventional TPE. In this case, the effectiveness of even the whole course of treatment was low. Conclusion: DFPP, and TPE are effective methods of the treatment of humoral rejection of renal graft only in case of sufficient dose of the procedure. Due to various influence on the biochemical parameters and hemostasis, indications for TPE and DFPP can vary considerably.


  IL-6 Concentration in Early Period after Kidney Transplantation Top


Aleksei Zulkarnaev, Andrey Vatazin, Dmitrii Artemov, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Kidney transplant always has ischemic injury. Ischemic injury causes the release of many mediators. One of the key inflammatory mediators is IL-6. We have studied the dynamics of its concentration in the early postoperative period after kidney transplantation, and the factors that influence on it. Aims of Study: To study the IL-6 blood concentration in recipients in the early postoperative period. Methods: The study included 28 patients. The selected time points: T0 – before surgery, T1 – 10–15 min after reperfusion, T2 – 4–6 h after reperfusion, T3 – in 12–14 h after reperfusion, and T4 – day after reperfusion. Results: At the stage T0, all patients had normal levels of IL-6. In most patients, after surgery, there was an increase of the concentration of IL-6. At the same time, the peak of concentration was observed at different stages, depending on various factors. In patients with good initial graft function peak of cytokine release noted on T1 or T2. In most patients with delayed graft function was an increase of the IL-6 concentration at 24th (T4) h after reperfusion. The peak of the release of IL-6 depends on of many factors: the length of warm and cold ischemia, a type of donor, and an initial graft function. Longer warm and cold ischemia can delay the release of IL-6. The warm ischemia has a greatest damaging effect on the initial graft function and character of the curve of concentration of IL-6. In a case of transplantation of kidneys from donors with brain death, peak release of IL-6 in the first 4–6 h after reperfusion can be expected. Conclusion: The study of IL-6 profile and the role of cytokines in the postoperative period in recipients of renal graft may identify new targets for specific therapy that might help improve the results of transplantation.


  The Race of Two Risks – Transplantation versus Time in the “Waiting List: How Can Be Found a Compromise? Top


Aleksei Zulkarnaev, Andrey Vatazin, Veronika Fedulkina, Vadim Stepanov, Rusudana Kantaria

Moscow Regional Research and Clinical Institute, Moscow, Russia. E-mail: 7059899@gmail.com

Background: Patients in waiting list (WL) present as quite a heterogeneous population and require a specific approach to risk stratification to allow for the choice of the optimal modality of renal replacement therapy (dialysis or transplantation [Tx]). Aims of Study: To analyze the relationship between the waiting time and the results of kidney Tx. Methods: We have analyzed the results of treatment of 1197 patients with CKD5, 483 of them received a cadaveric first kidney transplant, while the others did not: they remained on the WL, died, or dropped out (censored). We used the competing risk analysis to assess the reasons for the withdrawal from the waiting list. Results: The survival rate of recipients was 96%, 93%, and 86%, and survival rate of those on the WL was 94%, 77%, and 59% after 1, 3, and 5 years, respectively (P < 0.001). While among the recipients the annual mortality was relatively stable, that in the WL group increased significantly by the 5th year. Remaining on the WL for over 5 years increased the relative risk of death before Tx by 3.1 times (P < 0.001) and reduces the predicted 5-year survival rate post-Tx from 90% to 76% (P = 0.003). At the point of inclusion in WL, patients have an average cumulative illness rating scale (CIRS) of 11 (interquartile range 9.25, 13), after 5 years on the WL – 17 (12.25, 18.75) – P < 0.001. If the CIRS is >24 conversion of risk occurs: the risk of death after Tx is a little higher than that for patients remaining on the WL, there is no difference in the predicted annual survival rate in these recipients and those who are on the WL: 85% and 87% respectively, P = 0.511. Conclusion: Our study shows that when considering the question of Tx, it is necessary to stratify per risk. Remaining on the WL for over 5 years significantly reduces the predicted survival rate post-Tx.


  Successful Three-Way Organ Exchange: Key to Mismatched Live-Related Donor Top


Ankit Sharma, Sanjiv Saxena, Ravi Bansal, Irfan Ahmad, P. P. Singh, Jagdeep Balyan, Amit Malhotra

PSRI Hospital, New Delhi, India. E-mail: dr_ankitjabalpur@rediffmail.com

Background: Kidney paired donation (KPD) is the most cost-effective and efficient modality for transplanting patients with willing but incompatible live donors. The challenges faced in expanding KPD include the lack of a national database for incompatible pairs, lack of coordination, and data sharing between various transplant centers, lack of a separate dedicated KPD team, and no specific data pool between various centers. Aims of Study: To highlight the possibilities of KPDs as an alternative strategy for increasing living donor kidney transplantations in ABO-incompatible/cross match-positive pairs where transplant is not feasible. Methods: This was a case report. Results: Three pairs (husband and wife) were taken in this study. In one pair, husband had high level of donor-specific antibody while in other two pairs were ABO-incompatible and were not ready to undergo desensitization due to financial reasons. When we reviewed all three pairs, they were ABO-compatible match between transplant pairs. Induction with anti thymocyte globulin was given. They underwent transplant and there was no intraoperative or postoperative complication. All three recipients had normal serum creatinine and other parameters. They were maintained with triple immunosuppression. All three recipient and donors are having normal parameters after 1 month of transplant. Various challenges faced during this transplant were counseling of recipients and donors about three-way organ exchange and their advantages and outcome in this, organization of adequate number of OT, trained nursing staff and ICU back up, and all three transplants at same time with sequencing of pairs (color coding was done to avoid the confusion among staff). Conclusion: Three-way KPD can be a valuable and alternative approach in pairs where live donor renal transplant is not feasible due to other reason. This approach can expand the donor pool in patients of crossmatch-positive and ABO-incompatible pairs.


  Retroperitoneal Laparoscopic Living Donor Nephrectomy: Single-Center Experience Top


Forqan B. Shaikh, D. S. Ray, T. K. Saha, S. K. Bajoria

NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India. E-mail: forqanbs@gmail.com

Background: Retroperitoneal laparoscopic donor nephrectomy has been the standard procedure for renal transplantation. These techniques are considered less invasive for the donor, allowing lower postoperative analgesic requirements and faster return to daily activities. Aims of Study: To evaluate the feasibility, safety, and outcome of retroperitoneal laparoscopic live donor nephrectomy. Methods: Between July 2014 and July 2018, a total of 1700 living donors underwent consecutive three-port retroperitoneal laparoscopic donor nephrectomies. The initial retroperitoneal space was created by insertion of a catheter attached to a saline-filled mid-finger of a glove. The renal hilum and ureter were circumferentially mobilized. The tributaries of renal vessels were divided with clips; the ureter was sheared with scissors. The main renal vessels were controlled, using two Hem-o-lok clips placed at each proximal ends. The graft retrieved through the inguinal incision. Results: All the 1700 retroperitoneal laparoscopic donor nephrectomies were carried out successfully. The average operation time and mean warm ischemic time was 74 and 4 min, respectively. The average blood loss was 80 ml. No blood transfusion or open conversion was required. No major complication occurred in the donors and donors were discharge after an average of 4 days. Analgesia was maintained by transversus abdominis block bolus followed by rescue analgesia (visual analog scale score >3.5) by intravenous bolus fentanyl 50 mic intermittently. Serum creatinine levels returned to normal within 1 week. Conclusion: The modified approach of retroperitoneal laparoscopic donor nephrectomy could be a cost-effective and safe alternative for developing countries.


  Role and Scope of Plasmapheresis in Transplantation Top


Suhas Bavikar

Deenanath Mangeshkar hospital, Pune, Maharashtra, India. E-mail: drbavikar@yahoo.com

Background: Pathological substances, if removed by therapeutic plasma exchange (TPE), may improve kidney grafts are antibodies, immune complexes, cryoglobulins, myeloma-free light chains, endotoxins, and cytokines. These graft injury causing substances need to be large enough >15,000 Da so that they cannot be removed by high flux dialysis or hemofiltration, toxic with long half-life, thereby causing prolonged injury. TPE can be done with single filtration on hemodialysis equipment, double filtration to return autologous plasma after removal of culprit substance, and immunoadsorption– blood group substance antibodies to be soaked on respective blood group substance columns. Removing the pathogenic donor-specific antibody (DSA) has to be accompanied by stopping new antibody production by B-cell and plasma cell depleting immunosuppression. TPE benefits transplant in four ways: (1) by removing pathological substances, decreasing its strength, (2) unloading reticuloendothelial system-improving endogenous clearance, (3) stimulating cytotoxic lymphocytes, and (4) replacing deficient substance by possible large volume plasma infusion without causing fluid overload. In immunologically mediated, paraproteinemic conditions, immunoglobulin compartment shifts. 75% of immunoglobulin M (IgM) (anti-ABO antibody) and only 45% of IgG (pathogenic anti-HLA DSAs) is intravascular, and within 48 h of completion of session, IgM, IgG production returns to 40% of prepheresis level. IgG production is also characterized by a rebound phenomenon. Sensation of TPE after several procedures can result in pretreatment or even higher levels of IgG, if patient is not on immunosuppression. If one assumes, a negligible production of new Ig (due to concurrent immunosuppression) and the rate of extravascular to intravascular equilibration is approximately 1%–2% per hour, then five separate procedures over 7–10 days are required to remove 90% of the total initial body immunoglobulin burden. Additional treatments may be required if new antibody production occurs. Dose of plasmapheresis is defined as 1, 1.5, or 2 plasma volumes, depending upon amount of plasma removed 30-45-60 ml/kg of plasma, respectively. One plasma volume exchange removes 66% and two plasma volume exchange 85% of the substance. Aims of Study: To study the role and scope of plasmapheresis in transplantation – Aurangabad single-center experience. Methods: Aurangabad, Maharashtra, India kidney transplant program was started in 1991, and 1106 transplants were managed under my supervision till date. In this retrospective study, I sought to explore outcome of plasmapheresis in 30 renal transplant patients, who underwent 148 sessions of plasmapheresis by single filtration with hemodialysis equipment over 11 years. Male-to-female ratio was 24 as to 6, 5 preoperative TPE, 25 cases posttransplant. Average age is 37.1 years. Results: Response to therapy were: (1) 3/4 for desensitization success, (2) 5/5 for early acute ABMR reversal, (3) 5/5 partial response for late antibody mediated rejection, (4) 3/6 stabilization of graft function for chronic ABMR, (4) 5/5 for thrombotic microangiopathy reversal success. One patient had hyperacute rejection and graft nephrectomy. One myeloma kidney could not be salvaged. One MGRS case safely transplanted without free light chain injury. There was partial response in a case of recurrent focal segmental glomerulosclerosis. Conclusion: PE provides an effective mechanism to reduce preformed antibodies to a level where risk of hyperacute rejection is decreased. PE provides a temporary mechanism to reduce antibodies posttransplant to treat acute rejection. TPE reversed all of TMA cases in our experience. We could successfully transplant without postoperative myeloma cast nephropathy in a case of MGRS with preoperative TPE conditioning in addition to cybordexa regimen. Experience with recurrent FSGS treated with TPE-induced partial benefit, albuminuria stabilized to <1 g/day from >6 g/day diagnosed in 2nd month after kidney transplantation, rituximab 1 g + 9 TPE.


  Clinical Profile of Organ Donors and Kidney-Transplant Recipients in Deceased Donor Transplantation Program-Jeevandan Top


G. N. R. Patel, G. Swarnalatha, T. Gangadhar, Uttara Das, Raja Karthik

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: gnrpatel@gmail.com

Background: Renal transplantation is best modality of renal replacement therapy modality in end stage renal disease. The burden of end-stage renal disease is expected to increase further due to increasing prevalence of risk factors such as diabetes. Deceased donor transplantation is gaining its popularity. Donations are increased by than 50% with important changes in donor profile. Aim: To describe the clinical profile of organ donors in deceased transplantation program – Jeevandan. Materials and Methods: It is retrospective observational study. Deceased organ donors from Jeevandan program registry from January 2014 to July 2018 (4.5years) were included. Baseline data taken were age group, gender, blood group, cause of death, duration of intensive care unit (ICU) stay, inotropic requirement, urine output, serum creatinine, comorbidities, substance abuse and other parameters were assessed systematically. Results: In this study, total number of donations are 540; males and females were 73% and 27%, respectively. Majority of them are blood group O (50%), B (32%), A (15%), and AB (5%). Most common cause of death is road traffic accidents (65%), cerebrovascular accidents (26%), and others (9%). Age group between 20–50 years as 60%. Standard and expanded criteria donors were 81% and 19%, respectively. Mean ICU stay is 3.1 days. More than 95% required inotropic support to maintain blood pressure. Urine output was >50 ml/h in 74% of donors. Serum creatinine was <1.5 mg/dl in 65% donors. Diabetes mellitus and hypertension present in 12.1% and 17.9% donors, respectively. KDPI score was <50% in 71.07% donations. Among kidney-transplant recipients, 70% are males and 30% are females. Mean cold ischemic time is 411.06 min. 3.32% recipients were previous graft failures. Discussion: The deceased donation program has done relatively better in south Indian states. Telangana is one among best in country with 4.2 deceased donations per million population. Currently, many donors are being lost due to lack of early identification and poor maintenance. The present extended criteria donors are 19.3% and kidneys utilized are 13.5%. Concerned efforts are required increase the expanded criteria donations and organ utilization rate and take care of organ shortage.


  Profile of infections with unusual organisms among renal-allograft recipients at a tertiary center in South India Top


S. Aashish, G. Swarnalatha, Uttara Das, Raja Karthik, T. Gangadhar

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: gangadhartaduri@gmail.com

Aim: To study the clinical profile of renal-allograft recipients with infections with unusual organisms at a tertiary center in South India. Materials and Methods: A retrospective cross-sectional analysis of renal allograft recipients with documented infections with unusual organisms was conducted. Data were collected from patients who underwent renal allograft transplantation from June 2010 to July 2018. Results: A total of 16 patients were studied. Females were 4 (25%) and males were 12 (75%). Mean age of the patients was 37.64 ± 13.46 years. Chronic glomerulosclerosis was the most common etiology of native kidney disease. BK virus infection was present in five patients (27.8%). Cryptosporidiosis, adenovirus, and pneumocystis infections were present in three patients each (18.75%). Dengue infection was present in two patients (12.5%). Most of the infections occurred within a mean of first 12 months of posttransplant period, with the notable exception of BK virus infections, which occurred at a mean of 13th posttransplant month. Pneumocystis pneumonia and adenovirus pneumonia directly contributed to mortality of one patient each among this group. BK virus infections responded to modulation of immunosuppression and leflunomide in all the cases. Cryptosporidium infections responded to treatment with nitazoxanide in all the patients, but one patient with treated Cryptosporidium infection succumbed 3 months later to bacterial pneumonia. Pneumocystis infection treated successfully with co-trimoxazole in one patient, while another patient with pneumocystis pneumonia succumbed to the infection. Both patients with adenovirus infection succumbed to the infection. Patients with dengue infection had uneventful recovery. None of the patients had any history of receiving antirejection therapy or intensive immunosuppression immediately before the episode of infection. Graft dysfunction was noted in 11 out of 16 patients (68.75%). All the patients with BK virus infection (100%) had graft dysfunction. Permanent graft loss due to the infections occurred in two patients (12.5%). Conclusion: In addition to infections that occur in the posttransplant period with common, community-acquired organisms, renal-allograft recipients are susceptible to infections with unusual organisms that can be bacterial/viral/fungal or parasitic. A high index of suspicion is necessary to detect and treat these infections as patients may present with subtle signs/symptoms. Modulation of immunosuppression may be the only treatment in infections with certain organisms such as adenovirus infections. Unusual infections need not always be preceded by antirejection therapy or intensification of immunosuppressive regimen, and hence, close monitoring and follow-up are required.


  Cytomegalovirus Infection following Kidney Transplantation: A Single-Center Study from South India Top


T. Ramchander, G. Swarnalatha, Uttara Das, K. Karthik, T. Gangadhar

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: chanduxlnt@gmail.com

Background: Cytomegalovirus (CMV) infection is a common complication following kidney transplantation. Objective: To assess the incidence, risk factors, treatment, and outcome of CMV infection among renal-transplant recipients. Methods: It is a retrospective single-center study and we studied the renal-transplant recipients who underwent renal transplantation between January 2015 and January 2018 and total number of patients are 119. Baseline characteristics of all patients, investigations, presentation of CMV infection, and its treatment are noted. Results: Of 119, 13 (10.9%) patients had CMV disease. Ten (76.9%) patients were males; the mean age of participants was 33.4 years. Mean duration of dialysis was 13.1 months. The majority of cases (69%) received a kidney from a living donor, 31% from deceased donors. Induction with injection basiliximab was given to 6 patients of which two were live emotionally related transplantation. Delayed graft function was seen in three deceased donor transplants. The mean time for CMV positivity was 11.7 months. Seven (50%) patients presented with gastrointestinal symptoms (transaminitis in 3, enteritis in 2, and gastritis in 1). Four patients presented with respiratory symptoms. Leucopenia was seen in 3 (23%) patients. Nonspecific symptoms were seen in 3. Seven (54%) patients experienced CMV in the first 6 months posttransplant period, and among seven, three received induction therapy and two had new-onset diabetes after transplantation (NODAT). Among six patients who received induction therapy, 5 (84%) patients developed CMV disease in first 6 months. Late-onset CMV disease (>6 months) was seen only in live-related patients. All patients received IV ganciclovir based on GFR was given for initial 21 days followed by oral valgancyclovir. Five (38%) patients received 6 months therapy, 4 (31%) patients are on treatment, and 4 (31%) received treatment for <3 months because of side effects (3 had new-onset persistent cytopenia and 1 patient had combined rejection 1 month following CMV and we lost the patient because of septic shock). Complete recovery was observed in patients who received adequate treatment. CMV disease was higher in patients received induction therapy and antirejection therapy and with kidney graft impairment. Conclusions: CMV infection was a common complication in the first 6 months of kidney transplantation, particularly among patients received induction therapy and with kidney graft impairment.


  Is there a Short-Term Benefit for Steroid-Free Kidney Transplantation? Our Initial Experience Top


Remi George, V. Balaraman, Shankar, R. P. Senthilkumar, C. Vasudevan, Thirumalvalavan, A. Sheik

Department of Nephrology, Government Kilpauk Medical College, Chennai - 600 010, Tamil Nadu, India. E-mail: remi.george.thomas@gmail.com

Aim: A descriptive study to compare short-term outcomes of steroid-free renal transplant in living-related low immunological risk recipients with IL-2R blocker induction against conventional tacrolimus (Tac) + MMF + steroid protocols (Triple ISDS). Our objectives were to compare metabolic parameters for insulin resistance, insulin secretion, infection episodes, psychosocial parameters, and rejection profiles between the two groups. Materials and Methods: Steroid-free protocol was defined by complete avoidance of oral or intravenous steroids within 1–2 weeks of transplant. Patients were not randomized and the decision to withdraw steroids was vested with the nephrology team. All patients received basiliximab induction. A total of six cases of steroid-free protocol were compared with 11 cases of conventional triple immunosuppression. All cases were between 3 months and 1 year of transplantation. The short-term metabolic outcomes were analyzed by insulin resistance (body mass index, HOMA-IR, dyslipidemia, serum uric acid) and insulin secretion parameters (C-peptide levels and fasting insulin assay). Infections, Tac drug levels, and rejection episodes were compared between the two groups. Psychosocial analysis of depression, sleep, and physical appearance were obtained by questionnaire method and compared. Results: Among the metabolic parameters, serum triglyceride and C-peptide levels were statistically lower in the steroid-free group. Body mass index, HOMA-IR, uric acid, serum cholesterol, and fasting insulin levels did not show statistical difference between the groups. Negative correlation was established between Tac levels and C-peptide levels in the steroid-free group. Mild mood disturbances suggestive of early depression were higher in the conventional triple-drug group. Infection and rejection profiles were comparable between both the groups. Further Research: Is the higher Tac dosage in steroid withdrawal group negating the benefit of steroid withdrawal protocol? Is there an ideal Tac level in steroid withdrawal transplant to avoid beta cell damage – should we follow it up with a C-peptide level as well? Who is the ideal candidate for a steroid free renal transplant?


  Deceased Donor Renal-Transplant Outcomes: A Single-Center Experience Top


Jaiju James Chakola, M. Jayakumar, E. Ramprasad

Department of Nephrology, Sri Ramachandra University, Chennai, Tamil Nadu, India. E-mail: chakkokrulajacob@gmail.com

Background: The number of patients with end-stage renal disease (ESRD) is increasing and the gap between the demand for kidney transplantation (KT) and available donors is widening. Thus, deceased donation is very important to the donor pool for ESRD. Objectives: This study aims to determine the long-term graft and recipient outcome of deceased donor renal transplantation at SRMC from 2002 to 2018 and to determine the donor and recipient factors that affect graft and recipient survival. Materials and Methods: This is a retrospective cohort of deceased donor KT from January 2002 to December 2018. Data were reviewed and collected from transplant medical records. Recipient and donor demographic profile were expressed as frequency counts, percentages, and means with standard deviation. Kaplan–Meier analysis was used to determine graft and patient survival. Results: Among 725 kidney transplant recipient, 578 (79.7%) were from living donors and 147 (20.2%) from deceased donors. All patients were recipients of first transplant, and there were no cases of second transplant or ABO-incompatible transplant. The mean recipient age was 43.1 ± 10.7 years and 65.9% were males. The major causes of ESRD were presumed chronic glomerulonephritis (44.7%) and diabetic nephropathy (22.7%). All patients received induction therapy (90.1%) and 54.4% had tacrolimus-based immunosuppressive regimen. Of these, 45.5% received induction with daclizumab, while 27.2% each received induction with basiliximab or rabbit-antithymocyte globulin. The patient survival rate at 1, 3, and 5 years was 91%, 86%, and 73% while graft survival was 89%, 79%, and 68%, respectively. Infection was the leading cause of death, followed by cardiovascular disease. Patients with in-house donors, and hence, lower cold ischemia time (CIT), male donors, and younger donors had significantly better graft survival. Conclusion: There was an acceptable outcome of KT from deceased donors up to 5 years post-KT. The most common cause of death was infection. Among the recipient and donor factors, the donor's gender had effect on the graft survival in which male deceased donor KT had better graft survival compared to females and CIT was significantly associated with patient survival rate. There was no significant difference in graft survival with different types of induction agents or between patients with or without tacrolimus-based therapy.


  Spousal Transplantation: A Single-Center Experience Top


Jaiju James Chakola, M. Jayakumar, E. Ramprasad

Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu, India. E-mail: jayakumar.m@sriramachandra.edu.in

Aim: To study the clinical profile and outcome of spousal transplantation in our center from 2004 to 2018. Materials and Methods: It is a retrospective study. All patients undergone spousal renal transplantation in our center from June 2004 to May 2018 were included. Details about age, gender, socioeconomic details, viral status, type of relation, duration of marriage, causes of end-stage renal disease in recipients, number of transplantation, immunosuppression therapy, induction therapy, complication, and outcome of transplantation were analyzed. The data were analyzed using SPSS 16.0 for Windows. Results: Out of 498 transplants, 84 were spousal transplantation. Five percent of donors were males and 95% were females. The mean age of recipients is 52 ± 18.25 years. The mean donor age is 42 ± 16.1 years. The graft survival for 1 year, 3 years, and >5 years are 84%, 78%, and 67%. The patient's survival for 1 year, 3 years, 5 years, and 10 years are 91%, 87%, 71%, and 44%, respectively. Conclusions: Spousal transplantation is an important source of living donor renal transplantation, in spite of poor HLA matching, graft survival rate is similar to that of live-related donors. Spousal transplant should be encouraged in places where cadaveric organs remain scarce.


  An Observational Study on Thrombotic Microangiopathy in Posttransplant Patients: A Tertiary Care-Center Experience Top


Sarang Vijayan, G. Swarnalatha, Uttara Das, Raja Karthik, T. Gangadhar

Nizam Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: gangadhartaduri@gmail.com

Aim: To study the clinical profile and immediate- as well as long-term outcome of patients with biopsy-proven thrombotic microangiopathy (TMA) in transplanted kidneys. Materials and Methods: All posttransplant patients presented with acute graft dysfunction having biopsy-proven TMA in last 3 years were included. Those patient's baseline characteristics including native kidney disease, induction given, maintenance immunosuppression, and donor details were analyzed. The episode of acute graft dysfunction which led to TMA was evaluated in detail and patient was followed up. Results: Among the 145 renal transplants done in the last 3 years, eight patients had biopsy-proven TMA. All patients were young adults with mean age of 29.4 years. Seven patients underwent live-related renal transplant (87.5%) whereas only one patient underwent deceased donor transplant. Native kidney disease were chronic glomerulonephritis in 75% of patients with two having biopsy-proven focal segmental glomerulosclerosis and IgA nephropathy, respectively. Mother donated the kidneys in 62.5% of cases. Basiliximab was the induction agent given in only two cases were wife donated kidneys in one case, other being a deceased donor renal transplant. All patients were on triple immunosuppression with prednisolone, tacrolimus, and mycophenolate mofetil. During immediate posttransplant period within 1 month, two patients developed TMA whereas three patients had TMA in 1–6 months and rest three had TMA after 6 months posttransplant. Four patients had antibody-mediated rejection (AMR) and four had possible calcineurin inhibitors toxicity. Mean serum creatinine at initial presentation was 3.65. Only one patient has peripheral blood showing significant thrombocytopenia; none has any coagulation abnormalities. The patient with thrombocytopenia was already a diagnosed case of idiopathic thrombocytopenic purpura. Patients diagnosed to have AMR were given IVIG and plasmapharesis in all patients along with IV methylprednisolone and rituximab in two patients. In patients diagnosed to have possible CNI toxicity, CNI dose reduced and were started on everolimus later. On long-term follow-up, two patients had persistent graft dysfunction with serum creatinine maintaining between 2 and 2.5 mg/dl. Five patients had graft loss and two patients succumbed to death due to complications. Conclusions: TMA was more common in live-related renal transplant than deceased donor transplant possibly due to changes in induction protocol and dosage of immunosuppression. Common causes for TMA were acute AMR and CNI toxicity. Patients developing TMA in the posttransplant period had overall poor outcome on long term with high risk of graft loss.


  Pretransplant Seroprevalence and Posttransplant Reactivation of Opportunistic Viral Infections in Solid Organ Transplant Recipients: a Single Tertiary Care-Center Experience Top


Shefali Gupta, Supriya Mahajan, Viniyendra Pamecha1, Ekta Gupta

Department of Clinical Virology and 1Hepatobiliary Surgery, SGPGI, Lucknow, Uttar Pradesh, India. E-mail: drdharm1@rediffmail.com

Background: Viral infections account for 20% of the infectious complications in the postoperative period of the solid organ transplant (SOT) recipients. Herpes group of viruses are the most important viral pathogens associated with the same. Aim of Study: To determine the pretransplant seroprevalence of herpes viruses in liver-transplant (LTx) and renal-transplant (RTx) recipients and donors and determine posttransplant viral reactivation. Methods: A retrospective study was conducted for 130 SOT recipients (93 liver [LTx] and 37 kidney [RTx]) who underwent transplantation in our institute from January to December 2016. Pretransplant donor (D) and recipient (R) serological determinations for cytomegalovirus (CMV IgG), Epstein–Barr Virus (EBV IgG), herpes simplex virus (HSV1and2 IgG), and Varicella zoster virus (VZV IgG) were estimated by chemiluminescence immunoassay. Posttransplant DNA viral loads of herpes viruses were tested by qPCR (real time) up to 1 year. Patients with CMV DNAemia along with attributable clinical signs and symptoms were considered as having CMV disease. SPSS Version 20 based descriptive analysis has been done. Data were compared between donor and recipients and frequencies calculated. Results: Serological profiles for the donors and recipients are as follows: CMV IgG: 111 (94.9%) D+R+, 4 (3.4%) D−R+, 1 (0.8%) D+R− and 1 (0.8%) D−R−; EBV IgG: 73 (90.1%) D+R+, 6 (7.4%) D−R+, 2 (2.5%) D+R−; HSV IgG: 35 (44.3%) D+R+, 24 (30.4%) D−R+, 3 (3.8%) D+R− and 16 (20.3%) D−R− and VZV IgG: 56 (69.1%) D+R+, 14 (17.3%) D−R+, 19 (11.1%) D+R− and 2 (2.5%) D−R−. Posttransplant CMV DNA was positive in 31 (23.8%) recipients, 27 (29%) LTx and 4 (10.8%) RTx. Out of 31, 1 (3.2%) was high risk and 24 (77.4%) were intermediate risk and for six patients serostatus could not be determined. Posttransplant EBV DNA was positive in 2 (1.5%) LTx patients and both were high risk (D+R−). Median CMV viral load was higher in RTx (3.5 × 103 copies than LTx (5.0 × 102 copies). CMV was found in 19 (61.3%) and tissue invasive disease was seen in two LTx patients. Patients having >500copies were 21 (67.7%). Posttransplant CMV reactivation was highest in the 1st month 14 (59.2%), followed by 2nd month 13 (24%) and 3rd month 5 (9.2%). Median time of occurrence was 25 days. Conclusions: Pretransplant serological workup as well as documentation of herpetic viral infections (CMV and EBV) as early as in the 1st month of the postoperative period might alert the clinicians and guide them in effective patient management. However, more studies are needed to confirm our findings.


  A Retrospective Analysis of Etiology and Outcomes of Acute Pancreatitis in Rena-Transplant Recipients Top


D. S. Bhadauria, Venkatesh Thammishetti, Anupama Kaul, Manas Ranjan Patel, Narayan Prasad, Amit Gupta, R. K. Sharma

Department of Nephrology, SGPGI, Lucknow, Uttar Pradesh, India. E-mail: drdharm1@rediffmail.com

Acute pancreatitis after renal transplantation is a rare, but dreadful complication. As compared to general population it carries high mortality in renal transplant recipients. Etiology is not always identifiable and classical symptoms are always not present at onset which may cause delay in diagnosis. The available literature on pancreatitis in renal transplants is from case reports or case series. We retrospectively analyzed the etiology, clinical features, management, and outcomes of 21 patients who suffered acute pancreatitis after renal transplantation. Twenty-two patients (males 86%, age 36.1 years) were included. Etiology included gallstones, viral infections, and structural lesions. Although most patients had graft dysfunction, all had partial or complete recovery. Patient survival was good with 86% of the patients surviving the episode.


  Everolimus-Induced Pneumonitis after Renal Transplantation: A Case Report Top


Chandrashekar Annamalai, Umesh Lingaraj1

Apollo Hospitals, Bilaspur - 495 006, Chhattisgarh, 1Apollo Hospitals, Bengaluru - 560 076, Karnataka, India. E-mail: umeshl@hotmail.com

Abstract: Everolimus causes pneumonitis; however, less is published about it. We report a case of pneumonitis in a renal-transplant recipient on everolimus therapy from South India. Although no definitive etiology was discernible, pneumonitis resolved following suspension of everolimus, thereby implicating it as a potential cause.

Introduction

  • Everolimus is being increasingly used in renal transplantation owing to its antiproliferative properties and synergism with calcineurin inhibitors[1]
  • Severe adverse reactions such as interstitial pneumonitis can occur[2]
  • Early diagnosis is crucial since delayed discontinuation of the drug can prove fatal[3]
  • Data on everolimus-induced pneumonitis are sparse.[4]


Objectives

  • To illustrate the role of everolimus in the causation of pneumonitis
  • To highlight the importance of timely recognition and discontinuation of everolimus to prevent adverse outcomes.


Case Description

  • A 22-year-old male with end-stage kidney disease due to reflux nephropathy
  • No other co-morbid illness, teetotaler
  • Received a kidney allograft from cousin 2 years ago
  • ABO-compatible (B positive), 101 mismatch, negative FCXM, no DSA
  • Basiliximab induction, tacrolimus 2 mg BD, mycophenolate mofetil 1 g BD, prednisolone 10 mg OD
  • 3-month post-transplant, tacrolimus converted to everolimus 2 mg BD as per local institution protocol
  • Excellent graft function (serum creatinine 78 μmol/L) with no proteinuria
  • No rejection episodes
  • 7 months later, presented with shortness of breath, cough, and low-grade fever
  • Wet crackles over lung base on auscultation
  • The laboratory parameters are detailed in [Table 1].
Table 1: Laboratory findings

Click here to view


Management

  • Chest X-ray showed reticular opacities. High-resolution chest computed tomographic (CT) imaging revealed crazy pavement pattern of interstitial thickening and bilateral diffuse ground glass opacities involving bilateral lower lobes
  • Empiric therapy with broad-spectrum antibiotics, antifungal and antiviral proved ineffective
  • Bronchoalveolar lavage (BAL) demonstrated lymphocyte predominance. No eosinophils observed, suggesting no hypersensitivity pneumonitis. BAL fluid culture for bacteria, virus, fungus and Mycobacterium tuberculosis negative
  • Transbronchial biopsy indicated chronic nonspecific Interstitial pneumonitis
  • Severe type I respiratory failure necessitating assisted mechanical ventilation and intensive care
  • Drug-induced pneumonitis related to everolimus suspected. Everolimus discontinued and replaced with tacrolimus.


Outcome

  • Remarkable clinical improvement noted, discharged after 9 days
  • Chest CT imaging after 5 months showed resolution of pulmonary infiltrates
  • Renal allograft functions remained stable


Discussion

  • Everolimus therapy is a well-recognized cause of interstitial lung disease; incidence ranges from 4% to 11%[5]
  • Pathophysiology not well understood. Direct drug toxicity, immunological toxicity, or a combination of both proposed.[6] Dose-dependency controversial, interstitial pneumonitis reported with high, low, or acceptable trough levels of everolimus[7]
  • Clinical presentation heterogeneous and nonspecific, predominantly with dyspnea, cough, fatigue, and fever[2]
  • Diagnosis challenging and entails exclusion of infections, autoimmune diseases, or toxic causes[5]
  • Chest X-ray, high-resolution CT scan, bronchoscopy with BAL and surgical or transbronchial biopsy complement the diagnosis.[3] Clinical improvement following everolimus discontinuation can be confirmatory[5]
  • Delay in treatment fatal with mortality of 5%.[6] Elimination of everolimus leads to recovery of pneumonitis. High-dose corticosteroids may be needed in severe cases.[4]


Conclusions

  • This case report documents that everolimus induces pneumonitis at therapeutic blood levels[7]
  • EIP should be considered in transplant recipients presenting with respiratory symptoms[3]
  • Early diagnosis and prompt discontinuation of everolimus are essential to avoid irreversible pulmonary damage.[4]



  References Top


  1. Peddi VR, Wiseman A, Chavin K, Slakey D. Review of combination therapy with mTOR inhibitors and tacrolimus minimization after transplantation. Transplant Rev (Orlando) 2013;27:97-107.
  2. Molas-Ferrer G, Soy-Muner D, Anglada-Martínez H, Riu-Viladoms G, Estefanell-Tejero A, Ribas-Sala J, et al. Interstitial pneumonitis as an adverse reaction to mTOR inhibitors. Nefrologia 2013;33:297-300.
  3. Lopez P, Kohler S, Dimri S. Interstitial lung disease associated with mTOR inhibitors in solid organ transplant recipients: Results from a large phase III clinical trial program of everolimus and review of the literature. J Transplant 2014;2014:305931.
  4. Baas MC, Struijk GH, Moes DJ, van den Berk IA, Jonkers RE, de Fijter JW, et al. Interstitial pneumonitis caused by everolimus: A case-cohort study in renal transplant recipients. Transpl Int 2014;27:428-36.
  5. Errasti P, Izquierdo D, Martín P, Errasti M, Slon F, Romero A, et al. Pneumonitis associated with mammalian target of rapamycin inhibitors in renal transplant recipients: A single-center experience. Transplant Proc 2010;42:3053-4.
  6. Cravedi P, Ruggenenti P, Remuzzi G. Sirolimus for calcineurin inhibitors in organ transplantation: Contra. Kidney Int 2010;78:1068-74.
  7. Alexandru S, Ortiz A, Baldovi S, Milicua JM, Ruíz-Escribano E, Egido J, et al. Severe everolimus-associated pneumonitis in a renal transplant recipient. Nephrol Dial Transplant 2008;23:3353-5.



  Infections during Immediate Posttransplantation Period and Antibiotic Resistance Pattern of Microorganisms in Renal-Allograft recipients: A Study from Tertiary Care Center Top


Rohan Dwivedi, G. Anvesh, Sree Bhushan Raju

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushanraju@gmail.com

Introduction: Renal transplantation is the ideal method for treating patients with end-stage renal disease. While considerable advances have been made in organ transplantation and immunosuppression for renal transplantation, infections and antibiotic resistance are the major concerns in renal-allograft recipients. This study aimed to detect common bacteria and their antibiotic sensitivity patterns in kidney transplant unit. Material and Methods: A total of 82 patients from January 2018 to July 2018, in kidney transplant unit of NIMS, Hyderabad, were investigated. Qualitative urine culture, blood culture, drain fluid culture, and perfusion fluid culture were performed for all cases, causative microorganisms were identified, and colony count was performed according to the standard protocol. Antibiotic susceptibility testing was then performed to determine the susceptibility pattern of recovered bacteria from confirmed infection. Results: Cultures were positive in about 32.92% patients. 62.96% were male and 37.96% were female. 59.26% patients underwent deceased donor transplantation while 40.74% patient had live-related transplantation. 66.67% patients received induction immunosuppression while 33.34% patients went under transplantation without induction. Out of all culture positive, 33.33% were from blood and 66.67% from urine. The most common infecting bacteria were Klebsiella pneumoniae Scientific Name Search  (33.34%) followed by  Enterococcus faecium Scientific Name Search %) and  Escherichia coli Scientific Name Search 37;). K. pneumoniae showed high rate of sensitivity to colistin and tigecycline and high rate of resistance to carbapenems and fluoroquinolones. Enterococcus sp. had high rate of resistance to penicillins, flouroquinilones and were sensitive to vancomycin, linezolid, and teicoplanin. Most commonly prescribed antibiotics were colistin followed by linezolid, meropenam, and tigecycline. The rate of resistance to all tested antibiotics was highest in penicillins, cephalosporins, flouroquinolones, and carbapenams. Conclusions: These results highlighted increased infections with resistant organisms among transplant recipients. K. pneumoniae and Enterococcus species are major threats in kidney transplant units. Creation of a transplant-specific antibiogram may allow physicians to tailor better empiric therapy, monitor resistance rates, and improve patient and graft outcome.


  Emphysematous Pyelonephritis due to Mucormycosis in Renal-Allograft Recipient: A Case Report Top


Rohan Dwivedi, G. Anvesh, Sree Bhushan Raju

Department of Nephrology, NIMS, Hyderabad, Telangana, India. E-mail: sreebhushanraju@gmail.com

Introduction: Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the kidney and its surroundings, most commonly due to bacterial infections (Escherichia coli). Fungus as a cause of EPN is a rare occurrence. We report an extremely rare case of EPN caused by mucormycosis. Case Report: A 26-year-old man nonhypertensive, nondiabetic who underwent deceased donor renal transplantation, was hospitalized for right-sided lower lobe pneumonia due to Pseudomonas infection. He was successfully treated and discharged at stable graft function. Within few days ensuing discharge, he was readmitted because of fever and graft dysfunction. Despite antibiotics, antifungal and hemodialysis patient did not improve and died of sepsis. Postmortem kidney biopsy was done to identify the cause which revealed mucor. Conclusion: Primary mucormycosis of the renal allograft is a dreaded disease with grave prognosis. Deceased donor transplantation might be a possible risk factor. Fungal colonization may occur during transplantation. High index of suspicion and multimodality approach in the treatment including surgery, antifungal therapy, and management of risk factors are keys to favorable outcome.


  Profile of Rejections among Renal-Allograft Recipients at a Tertiary Center in South India Top


Neeharika, G. Swarnalatha, Uttara Das, Raja Karthik, T. Gangadhar

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: gangadhartaduri@gmail.com

Aim: To evaluate profile of rejections among renal allograft recipients at a tertiary center in South India. Materials and Methods: This was a retrospective analysis of renal allograft recipients who underwent renal transplantation either live or deceased, with or without induction, from 2015 to 2018 and all the patients were kept on maintenance triple immunosuppression. All the patients were followed up at regular intervals. At each visit, renal function was assessed with clinical history, urine output monitoring, and biochemical investigations. Patients who presented with graft dysfunction were assessed for etiology and biopsy done to rule out rejection. Patients with documented biopsy-proven rejections were treated according to protocol; their outcomes were assessed and included in the study. Results: Total number of patients who underwent transplant during study period was 145, 14.5% (20) patients had one or more number of rejection episodes, altogether 28 rejection episodes among 20 patients. Out of which, 47% (13) were antibody mediated, 21% (6) were cell mediated, 32% (9) were combined rejections. Early acute rejections (within 6 months) include 43% (12), whereas late acute rejections include 57% (16). Among patients with antibody mediated rejection as first rejection, 60% had complete recovery, 30% had partial recovery, and 10% not responded to treatment. Among patients with acute cell mediated rejection as first rejection, all (100%) patients had only partial recovery immediate posttreatment period. Among patients with acute cell mediated rejection as first rejection, only 50% had complete recovery immediate posttreatment period. During the second rejection period, no patient had complete recovery, 66% patients had partial recovery, 16% not responded to treatment, and 16% had mortality. During third rejection episode, 50% had partial recovery and 50% had mortality. After total duration of follow-up, among rejection patients, 19% patients succumbed to death, 5% had graft loss and reinitiated on RRT, 25% had stable graft function, and 25% had persistent graft dysfunction. Conclusion: ABMR is more common than ACMR and combined rejections in our study. Late acute rejections were more common than early acute rejections. Chances of renal recovery decrease as the number of rejection episodes increases. Morbidity and mortality are more common with combined rejections.


  Renal-Allograft Biopsy in Immediate and Early Posttransplant Period: Clinical profile, Indications, and Short-Term Outcome Top


K. B. Shashikiran, Rohan Dwivedi, G. Anvesh, D. Sree Bhushan Raju, D. Krishna Prasad, N. Vamsi Krishna

Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Background: Renal-allograft biopsy plays a crucial role in the diagnosis and treatment of graft dysfunction in renal-allograft recipients. It is a safe and very reliable procedure with very few adverse effects, while having significant implications in patient management. This paper describes the clinical profile of patients undergoing graft biopsy in immediate or early posttransplant period, indications, and outcome. Objectives: (1) To study the clinical profile of patients undergoing graft biopsy in the immediate or early posttransplant period, its indications, and complications. (2) To analyze the graft status at discharge. Materials and Methods: This is a retrospective cohort of renal-allograft recipients from January 2015 to December 2017. Patients who underwent graft biopsy within 1 month of transplantation or before hospital discharge were included in the study. The demographic characteristics, clinical features, indications, complications, and therapy received were obtained from hospital database. Patients were followed according to the institutional protocol and outcome. Results: Thirty-four out of 108 transplant recipients underwent graft biopsy. All of them were indication biopsies. None developed any major complications, while two patients had mild hematuria. Fourteen (41.1%) of those who underwent graft biopsy were deceased donor allograft recipients. Twenty-six (76.4%) of these patients had slow or delayed graft function. Eight (23.5%) patients with immediate graft function later developed graft dysfunction secondary to antibody mediated rejection in three, drug-induced acute interstitial nephritis in three, AIN secondary to tac toxicity in two. Most common pathological feature noted was acute tubular necrosis (ATN) in 15 (44.1%) of which two were attributed to acute cellular rejection. Five (14.7%) patients had graft pyelonephritis. One patient developed chronic thrombotic microangiopathy (ABMR, tac toxicity) and graft loss before discharge, while most patients were discharged with stable graft function. Conclusions: Graft biopsy is a simple, but a very important procedure in diagnosis and prognostication of graft dysfunction. ATN being the most common pathological feature is a common manifestation of diverse causations such as ischemia reperfusion injury, calcineurin inhibitor injury toxicity, and acute cellular rejection.


  A Live-Related Renal Transplantation with Renal Artery Stenosis in the Donor: A Case Report Top


K. B. Shashikiran, G. Anvesh, D. Sree Bhushan Raju, D. Krishna Prasad, N. Vamsi Krishna, B. N. R. Ramesh

Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Background: There is a change in the trend of acceptance of donor kidneys due to a huge mismatch between the availability and the demand of the organ transplants. Here with we report a live-related renal transplant with donor having atherosclerotic proximal renal artery stenosis (RAS). Objectives: To emphasize that donors with RAS are fit to donate for live-related renal transplantation. Materials and Methods: This was a descriptive case report of a 26-year-old renal-allograft recipient with her mother as donor. After obtaining informed consent, detailed patient information, clinical findings, diagnostic work up, therapeutic interventions, follow-up, and outcomes were noted. Results: A 26-year-old female patient with end-stage renal disease secondary to genitourinary tuberculosis underwent renal live- related renal transplant with mother as donor who had right renal artery ostium stenosis of about 60% detected on renal angiogram. The donor was normotensive, with unilateral atherosclerotic RAS. Intraoperative and posttransplant period was uneventful with immediate graft function. Both the donor and recipient are doing well on follow-up with stable graft function (serum creatinine of 0.6 mg/dl). Conclusions: Renal donors with mild anatomic renal vascular abnormalities could be used to increase the potential donor pool and decrease the waiting time for renal transplantation.


  Short-Term Outcome of Patients with Deceased Donor Renal Transplantation from Marginal Donors with No Induction Protocol: Single-Center Experience Top


K. B. Shashikiran, G. Anvesh, D. Sree Bhushan Raju, D. Krishna Prasad, D. Vamsi Krishna, B. N. R. Ramesh

Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Background: The idea of expanded criteria donors (ECDs) was conceived to combat the huge discrepancy between demand and organ availability. Kidney transplantation with ECDs does better than patients who remain on hemodialysis. However, earlier studies suggest that ECD kidneys have a higher propensity for delayed graft function (DGF) and poor outcomes. We present our experience of deceased donor renal transplantation using marginal donors and no induction protocol. Objectives: (1) To study the short term (at 6 months) outcome of patients receiving renal allograft from ECDs and no induction therapy. (2) To determine the donor and recipient factors that affect graft and recipient survival. Materials and Methods: This is a retrospective cohort of deceased donor renal transplantations from January 2015 to December 2017. Marginal donors included those who satisfied ECDs and/or donors with serum creatinine above 1.5 mg/dl. Recipient and donor demographic profile were expressed as frequency counts, percentages, and means with standard deviation. Kaplan–Meier analysis was used to determine graft and patient survival and logistic regression to establish correlation between certain factors and survival. Results: Twenty-three patients between 2015 and 2017 who received renal allograft transplantation from extended criteria donors were included. None of the patients included received induction therapy. Median age of the donors was 40 years (range 21–66 years) with average serum creatinine level of 1.6 mg/dl (range 0.6–4.0). Fifty two per cent of our patients had slow graft function/DGF. One patient expired secondary to septicemia and one had graft loss in the immediate posttransplant period secondary to Tac-induced TMA. At 6 months, patient survival was 91.3% and death-censored stable graft function of 90.4%. Conclusions: The ever increasing gap between the availability of donors and patients awaiting cadaver renal transplantation, retrieving kidneys from marginal donors can add significantly to the donor pool. The short-term results are favorable and encouraging.


  Reversible Nonischemic Cardiomyopathy after Orthotopic Liver Transplantation: A Report of Case Series from a Single-Center Experience Top


R. Rathi, S. Swaminathan, B. Joseph, L. Venkatakrishnan

Department of HPB and Liver Transplant and Gastroenterology, PSG Hospitals, Coimbatore, Tamil Nadu, India.

Introduction: Cardiovascular complications are a leading cause of nongraft-related death following liver transplantation (LT) and have been reported to occur in up to 70% of recipients. Nonischemic cardiomyopathy (NIC) is an early complication of LT. Candidates for LT undergo comprehensive cardiac evaluation before listing for LT to minimize complications and to ensure adequate cardiac function and reserve to withstand intraoperative hemodynamic instability and stresses during LT. The specific cardiac tests used for pretransplant evaluation generally include electrocardiography, echocardiography, cardiac stress test, and cardiac catheterization. Case Series: Patients undergone LT at our institution from September 2014 to April 2018 were considered. Patients who developed NIC were identified. Data collected included demographic and clinical data. A total 31 transplants were performed in this period and three patients developed NIC. Pretransplant dobutamine stress echocardiography was negative for ischemia and ejection fraction showed good LV systolic function. After liver transplant, three of the total 31 patients developed NIC. All the three had high MELD scores (15, 22, and 25, respectively). Median-onset of NIC was 2 days (range from 0 to 4). Echocardiograms posttransplant showed global left ventricular hypokinesia and a decrease in ejection fraction (EF) from a median of 74% (range, 66–78) before transplant to a median of 30% (range, 30–35). There was no significant difference between recipients with NIC versus recipients without cardiomyopathy regarding donor age, donor risk index, and cold and warm ischemia time. All were treated conservatively with beta blockers, diuretics, and ACE inhibitors. Recovery of cardiac function occurred in all three patients, with a median EF of 60% (range, 58%–62%) at the time of discharge. Conclusion: Patients who developed NIC were individuals who had advanced liver disease with a high MELD score. The etiology of NIC is unknown, but it is most likely multifactorial. Although NIC is a rare complication of LT, and in most cases, it is reversible, it can also cause significant postoperative morbidity requiring significant physiological support, a prolonged hospital stay, or mortality. Recognition of individuals at risk of NIC in the pre-LT or immediately post-LT period may be beneficial in reducing cardiovascular complications and may improve outcomes.


  Outcomes of Deceased Donor Renal Transplantation with No Induction Protocol: A Single-Center Experience Top


Sonu Manuel, G Anvesh, D Krishna Prasad, Sree Bhushan Raju, Vamsi Krishna, Ramesh

Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Background: Considering the huge disparity between the availability of organs and the number of patients waiting for renal transplant, deceased donor renal transplant (DDRT) is a novel way to expand the donor pool. Unfortunately, the frequency of DDRT is low in India with an estimated of 5% among the total renal transplants. We present our experience of DDRT and no induction protocol. Objectives: To study the clinical profile and outcomes of patients receiving renal transplantation from deceased donors and no induction therapy from a publically funded tertiary care center in South India. Materials and Methods: This study is a retrospective analysis of 59 DDRTs from January 2013 to June 2018. The data were reviewed and collected from the institution medical records. Demographic details of recipients and donors were studied along with outcomes in terms of delayed graft function (need of dialysis in immediate posttransplant period) mortality, rejection episodes, and patient and graft survival. All the transplants were blood group compatible. 44 patients completed a minimum of 1-year follow-up. Results: 73 of total 323 transplant patients received DDRT from 2013 to 2018. 59 of these patients did not receive any induction. 33% of donors and 26% of recipients were females. Median age of the donors was 39 years (range 18–66 years) with average serum creatinine level of 1.6 (range 0.6–4.0 mg/dl). 31% of our patients had delayed graft function. In immediate posttransplant period, there were four deaths (6.7%) and two graft loss (3.3%). Major cause of death was sepsis. Mean creatinine at discharge was 1.3 mg/dl. Incidence of rejection was 15.2%. Patient survival and graft survival were 86.3 and 93.1, respectively, at 1-year follow-up. Death-censored graft survival at 1 year was 99%. Conclusions: DDRT shows a fairly successful outcome with good graft function and patient/graft survival with no induction protocol. Proportion of female patients undergoing transplantation was more in our study and sepsis was found to be the major cause of death.


  Spousal Renal Donor Transplant: A Tertiary Care Center Experience from South India Top


A. Faizan, G. Anvesh, Vamsi Krishna, Ramesh, Sree Bhushan Raju

Department of Nephrology, Nizam Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Introduction: In India, the Transplantation of Human Organ Act came into force in 1995. It allows removal of cadaver organs for transplantation and to regulate living-unrelated renal transplant. It allows for organ transplant between near relatives which include parents, siblings, children (over 18 years), and spouse. Deceased donor organ shortage has made living donors major source for renal transplant in our country. We carried out a retrospective study of spousal renal transplant at our center. Methods: It was a retrospective single-center study from January 2010 to June 2018. Demographic profile, patient survival, graft survival and function, rejection episodes, and mortality rates were evaluated. Results: Mean recipient age was 26 ± 8 years. Wives were donors in 57 (93.4%) cases. Mean HLA match was 0.18 ± 0.46. Delayed graft function was noted in 4 (6.5%), slow graft function in 3 (4.9%), immediate graft function in rest all 54 (88.5%). Average serum creatinine was 1.4 ± 0.8 at discharge. Immediate complications were noticed in 24 (39.3%) patients. Acute tubular necrosis (ATN) was seen in 8 (13.1%) patients, 5 had tacrolimus toxicity, and 4 had ischemic ATN. Immediate Infectious complications seen in 10 (16.4%) patients, of which seven had urinary tract infections, Escherichia coli being the most common organism. Acute rejections were noted in 7 (11.5%) patients. 10 (16.4%) patients expired and 8 (13%) had graft loss during follow-up. Conclusion: Spousal donation is a viable option in present scenario of organ shortage and unavailability of well-developed ABO-incompatible transplant in our country.


  Cavitatory Pneumonia in a Renal Transplant Recipient: A Case Report Top


Introduction: Invasive zygomycosis or mucormycosis is an extremely rare but potentially fatal infection following renal transplantation. Mucormycosis represents a small amount of IFIs in kidney transplants with incidence of 0.2-1.2%. The overall mortality rate of mucormycosis ranges from 38% to 56.5%. Mortality has been reported from 33% to 60% for isolated pulmonary infection, 10% to 17% for cutaneous infection, and 31% to 93.3% for rhinosinus infection (98% when disseminated to the central nervous system). Case Report: A 59-year-old male with chronic kidney disease on dialysis, NKD-Diabetic nephropathy, underwent renal transplantation (spouse donor). Induction was given with Anti thymocyte globulin at 2 mg/kg and the patient was on tripple immunosuppression consisting of Tacrolimus, MMF and Wysolone. Patient was discharged on post operative day 10 with serum creatinine of 0.8 and with good urine output. After 5 months of post transplantation, the patient presented with cough with expectoration with dyspnea and loss of appetite of 3 days duration.

  • Vitals: Pulse rate-90 bpm, blood pressure-130/90 mmHg, mild dehydration-positive
  • Systemic examination: Respiratory system: bilateral NVBS+, crepitation present over left interscapular and infrascapular area. Other systems were normal
  • Investigations: Basic investigations revealed anemia with normal total counts. RBS 384 mg/dl, HBA1c 8.1. Creat-1.2 mg/dl. USG Abdomen-normal transplant kidney. Sr Tacrolimus C0 level-18.8 mcg/lit. Urine culture-Klebsiella 100,000 cfu/ml. Blood culture-No growth. CMV PCR-24,500 copies/ml. Computed tomography (CT)-thorax revealed thick-walled cavity 5 cm × 5.7 cm in posterior basal segments of left lower lobe with apical segment of right upper lobe consolidation. BAL fluid: Gram stain-occasional pus cells, No organism. AFB stain-Negative. KOH stain-No fungal elements. Culture-No growth. Fungal culture-No growth. Galactomannan index-<0.5. B-D-Glucan-23 pg/ml (normal <60 pg/ml). The patient was started on IV antibiotics. CT-guided lung biopsy-Acute and chronic inflammatory infiltrate with lymphocytes and eosinophiles. Foci of broad aseptate fungal hyphae with irregular branching-MUCOR Special stains and PAS-Positive. Immunohistochemistry for CMV-Negative. Treated with injection amphotrecin-B iv 1 mg/kg. injection ganciclovir 5 mg/kg BD × 1week. Valcyte 450 mg 1-0-1. Repeat CT thorax (3 weeks): Thick-walled cavity size 3.9 cm × 2.6 cm postbasal segments of left lower lobe. Fibrosis in basal segments of left lower lobe and apical segment of right upper lobe. The patient was currently asymptomatic. S. creatinine 0.9 mg/dl. Plan: Injection amphoterecin-B for a cumulative dose of 2 g lobectomy.
Discussion: The incidence of mucormycosis in renal transplant recipients ranges from 0.2%–1.2%. The above patient had many risk factors such as use of induction agent, immunosuppression status, renal failure, CMV infection, and uncontrolled diabetes mellitus. Pulmonary involvement in solid organ transplant recipients accounts for 39% of cases. CT features of pulmonary mucormycosis in SOT recipients include consolidation or mass-like lesions, nodules, or cavities. Initially, BAL done was inconclusive and diagnosis was made after tissue biopsy which is gold standard for diagnosis. Amphotericin B (AmB) is considered the drug of choice. The patient was started on injection amphotericin, injection ganciclovir, and immunosuppressants were reduced. Mortality associated with mucormycosis may be in part due to delays in diagnosis and initiation of appropriate therapy. Surgery is an essential part of the management of localized disease, and surgical resection is associated with improved outcomes. Lobectomy and nephrectomy are useful in isolated pulmonary and renal disease, respectively. Conclusion: Early diagnosis, aggressive surgical debridement in conjunction with an intravenous antifungal therapy and immunosuppression reduction or withdrawal have favorable outcome.


  A Case of Posttransplant Anti-Glomerular Basement Membrane Nephritis: A Diagnostic Dilemma Top


Mamidi Varun, E. Ramprasad, S. Manikanthan, M. Jayakumar

SRMC, Chennai, Tamil Nadu, India.

Introduction: Posttransplant anti-glomerular basement membrane (GBM) disease occurs in 5% of Alport patients and usually ends in irreversible graft failure. Usually, it occurs within the 1st year following transplantation. It was first reported by McCoy et al. in 1982. Case Report: A 20-year-old male with hypertension and end-stage renal disease secondary to Alport syndrome with dialysis vintage of 4 years underwent deceased donor renal transplantation on May 29, 2016. ATG induction was given and patient is on triple immunosuppression (tacrolimus, MMF, and wysolone). Nadir serum creatinine posttransplant is 0.9 mg/dl. In March 2017 (10 months posttransplant), the patient developed allograft dysfunction (serum creatinine – 1.6 mg/dl). Allograft biopsy done showed interstitial fibrosis and tubular atrophy grade 1. In May 2018 (24 months posttransplant), he presented with worsening renal failure (serum creatinine – 3.2 mg/dl). Renal biopsy done showed antibody mediated rejection with acute cellular rejection. The patient treated with five cycles of plasmapheresis and 100 g intravenous immunoglobulin. He discharged with stable creatinine of 2.8 mg/dl. In June 2018 (25 months posttransplant), he presented with serum creatinine – 4.2 mg/dl. Third renal biopsy was done which showed thrombotic microangiopathy with the presence of epithelial proliferation and linear IgG staining on GBM in one glomerulus. Hence, possibility of coexisting anti-GBM disease in this patient whose native kidney disease was Alport syndrome was considered. The patient was suspected to have posttransplant anti-GBM nephritis. Anti-GBM antibodies (ELISA) were negative. However, ELISA anti-GBM test was not very sensitive to anti-alpha 5 (IV) antibodies. Hence, the patient was treated with 15 cycles of plasmapheresis and 100 mg of IVIG, underwent three cycles of hemodialysis, and was started on 100 mg/day oral cyclophosphamide therapy. Patient renal function improved with cyclophosphamide therapy and he became dialysis independent with stable serum creatinine of 3.8 mg/dl. Two months later, the patient developed respiratory sepsis hence cyclophosphamide was stopped and the patient became dialysis dependent and is now on twice weekly maintenance hemodialysis. Discussion: Due to limited ability to identify high-risk patients, diagnosis of posttransplant anti-GBM nephritis requires high index of suspicion. Monthly anti-GBM antibodies by ELISA for 12 months following transplantation with frequent serum creatinine monitoring and low threshold for biopsy would be a reasonable approach. IV methyl prednisolone, plasma exchange, and cyclophosphamide are instituted in few studies but with limited benefit.


  Deep Venous Thrombosis Occurring Early Postrenal Transplant Top


Vamsi Krishna Makkena, S. Manikandan, E. Ramprasad, M. Jayakumar

SRMC, Chennai, Tamil Nadu, India. E-mail: MJK_MMC@Yahoo.co.in

Introduction: Deep venous thrombosis (DVT) is one of the major medical problems affecting 2.5 million people in the United States. In kidney transplant recipients (KTRs), there can be an increased risk of thrombotic diseases. Here, we report a case of KTR who developed ipsilateral acute iliofemoral DVT. Case Report: A 38-year-old male with end-stage renal disease underwent deceased donor renal transplantation with the graft vessels anastomosed to the external iliac vessels. He received antithymocyte globulin induction (2 mg/kg) and was maintained on triple immunosuppression with tacrolimus, mycophenolate mofetil, and steroids. He had delayed graft function (DGF) and underwent five cycles of hemodialysis, with renal biopsy showing acute tubular necrosis. He was discharged on day 15 with creatinine of 1.8. One month posttransplant, the patient presented with right lower limb edema, with Doppler showing DVT of right external iliac, common femoral, and proximal superficial femoral veins. He was treated with unfractionated heparin and underwent placement of retrieval filter in the infrarenal IVC via right femoral vein. Heparin was overlapped and switched to oral acenocoumarin. At 3-month postoperative, the patient is stable with no limb edema and serum creatinine of 0.8 mg/dl. A follow-up venous Doppler demonstrated the resolution of the thrombus. Discussion: Our patient developed DVT within 30 days postoperative with no apparent risk factor and was successfully treated with anticoagulation and placement of IVC filter. Acute iliofemoral DVT is a rare event after renal transplant. Venography, thrombolysis, and thrombectomy pose challenges in the KTRs because of increased risk of adverse effects such as bleeding, contrast-induced nephropathy, and pulmonary embolism.


  Anatomical Variation in Confluence of Retroperitoneal Veins with Left Renal Vein in Transperitoneal Left Laparoscopic Donor Nephrectomy Top


Rakesh Khera, Prasun Ghosh

Department of Urology, Renal transplant and Robotics, Medanta The Medicity, Gurgaon, Haryana, India.

Aim: To study anatomical variation of the posterior lumbar tributaries of the left renal vein in transperitoneal left laparoscopic donor nephrectomy. Introduction: Laparoscopic donor nephrectomy is standard procedure for procurement of graft during renal allografting in the present era. Skilled tackling and division of lumbar veins, which course and number are highly variable, are critical step to dissect the renal artery till base and get adequate length of renal artery and vein. Material and Methods: A total of 1381 cases of transperitoneal living donor nephrectomy were carried out from January 2010 to July 2016. 170 right-sided donor nephrectomies were excluded. The cohort of 1211 patients consisted of both Indian and international patients. All donations were voluntary and cleared by ethical committee. Majority of the donors 859 (78.54%) were female. Mean age of donors was 47.1 ± 13.7 years. Mean age of male donors was 48.2 ± 12.6 and female donors was 46.8 ± 13.9 years. Computed tomography angiography was performed in all cases. All surgery was performed in right lateral position with overextension by a single surgeon. The pattern of lumbar vein insertion into left renal vein was classified as follows: Type I (inferior), II (posterior), III (superior) aspect of renal vein, IV (2 or more veins joining together before insertion), V (draining into gonadal vein), and VI (other variable/no vein). The lumbar vessels in all cases were clip ligated and divided with harmonics. Results: veins: Type I – 434 (35.8%), II – 302 (24.9%), III – 3 (0.2%), IV – 369 (30.4%), V – 3 (0.2%), and type VI – 100 (8.2%), respectively. Conclusion: Intraoperative orientation to various pattern of drainage of lumbar veins can avoid troublesome bleeding and retain benefits of minimally invasive surgery.


  Isolated Liver Transplantation in Atypical HUS –: A Complete and Cost-Effective Cure – A Rare Case Scenario Top


Ranjani Ravi, Satish Balan, Praveen Murlidharan, R. Kashi Visweswaran, Venugopal, Shabbir, R. Shiraz

Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India. E-mail: rkasivis@yahoo.com

Atypical hemolytic uremic syndrome is disorder of complement dysregulation causing complement-mediated damage, resulting in hemolytic anemia, thrombocytopenia, and renal failure in susceptible individuals. Earlier, the treatment guidelines for this syndrome were based on plasmapheresis and replacement of complement-deficient plasma with fresh plasma. However, this modality of treatment was not patient-friendly. It involved lifelong apheresis, creating problems of long-term access, and sensitization to blood products. Furthermore, plasmapheresis did not have much effect on preventing progression to end-stage renal disease. The introduction of eculizumab heralded a new era in the treatment with a near magical response. However, the duration of therapy with eculizumab is not established. Moreover, the cost of the drug is a major deterrent in clinical practice, especially in India. In fact, it is not available in our country and has to be procured from other countries for use. Till date, there has only been one other case report of the use of eculizumab in India. Liver transplant offers an alternative by replacing the offending organ by a healthy liver capable of synthesizing normal complement proteins, thereby effecting a complete cure to the disease. Here, we present the case of a 26-year-old female, who presented in the postpartum period with features suggestive of microscopic hemolytic anemia and thrombocytopenia with dialysis requiring renal failure. She was proven to have complement factor H mutation-mediated atypical HUS by genetic studies. Her initial symptoms were controlled with eculizumab. However, after the initial weekly dose, she required weekly injections of the same for survival. She was not able to afford this treatment and was offered the alternative of liver transplant. Her husband was worked up as a donor and she underwent the transplant as per the consensus guidelines. The transplant was successful. There was no evidence of disease activity in the posttransplant period as evidence by a normal peripheral smear. Although she required sessions of hemodialysis and fluid removal in the immediate postoperative period, her renal parameters stabilized later. She is presently on follow-up and has no evidence of disease activity during follow-up for the last 6 months. We present this unique case as in the Indian setting; liver transplant is a much better financial alternative to patients with complement factor H mutation and is a onetime treatment and cure.


  The Effect of Bortezomib on Antibody-Mediated Rejection after Kidney Transplantation Top


K. Suthar, S. Jethwa, S. Balan, P. Muralidharan, M. Safeer

Kerala Institute of Medical Science, Trivandrum, Kerala, India.

Purpose: Bortezomib has been used to treat antibody-mediated rejection (AMR) in addition to conventional treatment such as plasmapheresis, intravenous immunoglobulin, and rituximab. There are many reports of success in treating AMR with this agent. In the Indian context, it is considerably cheaper than other agents available. Materials and Methods: During the last 2 years, we had twelve episodes of steroid-resistant AMR in the first 6 months after transplant. The patients received one or two cycles of bortezomib (1.3 mg/m2) on days 1, 4, 8, and 11. Clinical status and serum creatinine were followed up for 2 weeks. Results: Overall, there was a significant improvement or stabilization in the serum creatinine levels after therapy versus serum creatinine at time of AMR diagnosis. All 12 early-onset AMR episodes (within 6-month post-transplantation) showed full recovery or stabilization of allograft function. Conclusion: Anti-humoral treatment based on bortezomib appears to be an effective strategy against AMR. Thus it could prove cost-effective in the management of early-onset AMR.


  Open-Labeled Prospective Randomized Controlled Trial of Calcium and Vitamin D on Bone Health in Kidney-Transplant Recipient Top


R. Pandey, D. Sen, S. Dasgupta, Sudhanshu Sekhar Bhoi

Department of Nephrology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India. E-mail: rajensankrityan@gmail.com

Background: Bone loss occurs during the first 6 months after renal transplantation, and corticosteroid therapy plays an important role. Although calcium plus Vitamin D administration prevents corticosteroid-induced osteoporosis, its use in kidney transplant recipients is limited by the risk of hypercalcemia. Aim of Study: To study the effect of calcium and Vitamin D on bone health in renal-transplant recipient. Methods: This is open-labeled, prospective, randomized controlled intervention trial examining the effect of daily calcitriol (0.25 μg/day) and calcium supplementation(0.6 gm/day) in the first 6 months after renal transplantation (case), with only calcium supplementation (0.6 g/day) in control arm. The primary outcome measure was the change in bone mineral density (BMD) at 6 months after transplant. Twenty-one recipients were randomized to calcitriol and 20 were randomized to calcium only. All the patients were on triple immunosuppressant (tacrolimus/MMF/steroids). Results: Both groups had a similar degree of preexisting hyperparathyroidism (187 ± 229 vs.191 ± 183 pg/mL), but a more pronounced decrease of parathyroid hormone (PTH) levels after renal transplant was observed in patients on calcitrol (at 6 months: 60.4 ± 42.2 vs. 85.7 ± 53.1 pg/mL, P = 0.02). Patients on calcitriol preserved their BMD at neck of femur significantly better than those on only on calcium (6 months: 0.04 ± 3.3 vs. −1.93 ± 3.2%, P = 0.01). Differences did not reach significance at the lumbar spine and radial bone. Two patients on calcitriol (9.52%) and one patient on calcium only (5%) developed a hypercalcemia during the first 6 months after renal transplant. Conclusion: Therapy with low-dose calcium supplements and calcitriol for 6 months after kidney transplant, is safe, decreases PTH levels more rapidly, and prevents bone loss in neck of femur.


  An Interesting Case of Chronic Allograft Dysfunction Top


A. Srivatsa, Niranjana, Biswajith, Varun Mamidi, Vamsi, M. Jayakumar

Department of Nephrology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India.

Background: Among renal transplants, chronic allograft dysfunction is defined as a condition in which irreversible damage to the kidney allograft occurs over a period of months. Here, we report a case of late presentation of graft dysfunction due to BK virus with negative urine decoy cells and negative BK virus DNA PCR. Case Report: A 18-year-old young male underwent renal transplantation following which renal functions recovered to creatinine of 0.8 mg/dl with mother being donor. The patient was compliant and on regular follow-up. After 1 year of renal transplantation, patient's creatinine was found to be 2.1 mg/dl with no symptoms and signs. The patient was admitted and was evaluated. Urine showed no proteinuria; blood and urine cultures were negative with normal counts. Ultrasound of transplant kidney showed no issues. Tacrolimus levels were within limits. All reversible factors contributing were ruled out. Viral etiology was sought for. CMV IgM was negative. Urinary decoy cells were not seen. BK virus DNA PCR also turned out to be negative. BK virus was ruled out of differentials. During the course of hospital stay, creatinine worsened to 2.7. At this stage, notwithstanding, renal biopsy of transplant kidney was done. Biopsy showed features of BK virus nephropathy with viral cytopathic changes of the tubular cells. Discussion: Among alloantigen-independent causes of chronic allograft dysfunction, and among infections, CMV is the most common. Infections do appear in the early posttransplant period when the patients are most immunosuppressed. BK virus is a polyomavirus hominis 1 which causes polyoma virus associated nephropathy in humans is seen in ˜ 5% of kidney transplant recipients and has emerged as an important cause of allograft dysfunction over the last 20 years with 5-year graft failure rate of 55% presenting with asymptomatic increase in serum creatinine. BK virus is diagnosed by decoy cells in urine seen in over 90% of the infected patients. BK virus DNA PCR is very sensitive. The gold standard was renal biopsy of transplant kidney with tubulointerstitial nephritis, inclusions in tubular cells, and immunohistochemistry confirming BK virus. In our case, interestingly, decoy cells and DNA PCR were negative with positive biopsy for BK virus. In our case, mycophenolate mofetil was stopped. The patient was treated with leflunomide, following which patient's creatinine came down and stabilized at 2.5 mg/dl. Conclusion: BK virus nephropathy is a great masqurader which may often camouflage itself and misguide the clinician with negative urine decoy cells and PCR. Prompt workup is necessary including renal biopsy if clinically suspicious. This is one such case report where BK virus nephropathy was diagnosed.


  Complications and Outcomes of Critically Ill Adult Patients with Acute Kidney Injury or End-Stage Renal Disease Requiring Continuous Renal Replacement Therapy Top


K. B. Shashikiran, N. Vamsi Krishna, D. Sree Bhushan Raju, G. Anvesh, D. Krishna Prasad, B. N. R. Ramesh

Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: kbshashikiran@gmail.com.

Background: Continuous renal replacement therapy (CRRT) has evolved as renal replacement therapy of choice in critically ill patients. Although CRRT offers several theoretical advantages, complication rates and mortality have remained high over the last several years. This study enumerates the complications, short-term outcome, and in-hospital mortality predictors associated with CRRT. Aims and Objectives: (1) To study the electrolyte disturbances and other complications associated with CRRT. (2) To study the short-term outcomes and predictors of in hospital mortality in patients receiving CRRT. Material and Methods: This was a single-center retrospective observational study over a 2-year study period. All patients >18 years of age receiving CRRT from various intensive care units of Nizam's Institute of Medical Sciences were included. Patients who received CRRT for <12 h were excluded. Demographic and clinical data were recorded and analyzed using SPSS 19.0 v. Recovery of renal function was defined as the absence of ongoing renal replacement therapy at the time of discharge. Results: One hundred and twenty patients who received CRRT were included in the final analysis. Mean age of patients in our study was 54.7 ± 13.9 years. Male-to-female ratio was 1.7:1. Mode of renal injury was acute kidney injury (AKI) in 64 (53.3%) AKI on CKD in 36 (30%) and end-stage renal disease (ESRD) in 20 (16.7%) The most common comorbid factors contributing to the Charlson score in our study include diabetes mellitus (45.8%), congestive heart failure (20%), and malignancy (10%). Most common indication for initiation of CRRT was septic shock accounting to 61.6%. Electrolyte disturbances associated with CRRT in our study were hypokalemia (61.6%), hypophosphatemia (30.38%) and hypomagnesemia (15%). Hypotension during CRRT was noted in 57 (47.5%) patients. Bleeding episodes were seen in 9 (7.5%) patients which include GI bleed (5), hematuria (2), epistaxis (1), and cerebellar hemorrhage (1). Overall in-hospital mortality was 78.3% and it was 78% and 80%, respectively, in AKI and ESRD groups. Renal recovery was seen in 20 out of 22 patients who survived to discharge in AKI group. The factors found to have significant association with in-hospital mortality in AKI group include admission to medical intensive care unit, lactate >3 mmol/L, serum albumin <3 g/dl, need of mechanical ventilation, and ≥2 ionotropic support. Only serum albumin <3 g/dl was found to have significant association with in-hospital mortality in ESRD group. Conclusion: Electrolyte disturbances such as hypokalemia and hypophosphatemia are commonly seen in patients undergoing CRRT. Predictors of mortality differ between AKI and ESRD groups, likely reflecting differences in the clinical processes that lead to initiation of CRRT.


  Histopathological Spectrum of Renal Biopsies in Patients with Chronic Liver Disease Presenting with Renal Dysfunction Top


K. B. Shashikiran, Rajesh Goli, D. Sree Bhushan Raju, G. Anvesh, D. Krishna Prasad, N. Vamsi Krishna

Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: sreebhushan@hotmail.com

Background: Renal failure in patients with chronic liver disease (CLD) can be multifactorial. Studies describing the pathological features of renal biopsy in these patients are sparse. This study describes the histopathological spectrum of renal involvement in patients with CLD. Objectives: To study the histopathological pattern of renal biopsies in patients with CLD and renal dysfunction. Materials and Methods: In this retrospective study, patients with compensated CLD and renal dysfunction were included. Proteinuria >0.5 g/day and/or hematuria and/or unexplained high serum creatinine levels >1.5 mg/dl were the indications for renal biopsy. All biopsy specimens were examined by the same pathologist with light and immunofluorescence microscopy. Demographical, clinical, and histopathological data were recorded. Descriptive statistics was used and results were expressed as frequencies, percentages, and mean ± standard deviation. Statistical analysis was carried out using SPSS ver. 20. Results: Over a study period of 2 years, 40 patients of CLD with renal involvement underwent renal biopsy. Male-to-female ratio was 7:1. The mean age of patients included was 48.12 ± 1.5 years. Comorbidities associated were hypertension in 57.5%, diabetes mellitus in 37.5%, and both in 32.5%. Predominant etiologies of CLD in our patients were alcoholic liver disease in 45% followed by hepatitis B virus associated CLD in 22.5% and hepatitis C virus associated CLD in 7.5%. Twenty-eight (70%) of them had associated glomerular disease, of which IgA nephropathy (22.5%) was the most common followed by diabetic glomerulopathy (20%). Nonglomerular lesions such as chronic injury of renal vessels and/or the tubulointerstitial system were found in >70% of cases. Complications noted were gross hematuria in 15% of patients and perinephric hematoma in 7.5%; none required blood transfusion or surgical drainage. Conclusions: Renal biopsy is safe and can yield important diagnostic and prognostic information in patients with chronic liver disease presenting with renal dysfunction.


  Impact of Cytomegalovirus Infection in Postrenal Transplant: A Single-Center Experience Top


Objectives: To study the incidence and risk factors of cytomegalovirus (CMV) infection in postrenal-transplant recipients. Materials and Methods: Between January 1, 2014, and December 31, 2016, we have obtained detailed information and pretransplant CMV status of 910 recipients and donors. The enzyme-linked immunosorbent assay was the method is used to define serostatus, while CMV infection was diagnosed by CMV DNA detection with a polymerase chain reaction. Patients underwent the required hematological, biochemical, radiological, and endoscopic investigations. Results: A total of 78 of 910 (8.6%) patients were diagnosed with CMV disease. The mean age of presentation was 42 ± 11.6 years, with 69.2% men. Malaise (61.53%) and fever (51.28%) were the most common presenting symptoms. 42 had leucopenia and 37 had thrombocytopenia. Diabetes (21.8%) and hepatitis C virus (14.1%) were the most common comorbid conditions. The incidence of CMV disease was 8.8% in steroid + tacrolimus + MMF group while 7.2% in steroid + tacrolimus + AZA group. CMV disease was seen in 8.7% of patients who had received antithymocyte globulin (r-ATG) as induction while 5.6% of patients with basiliximab as induction therapy. Mean CMV DNA at diagnosis was 66872 copies/ml, 65.4% patients developed CMV after 6 months posttransplantation, the majority occurring within 6–12 months. Over the mean follow-up of 3 ± 1.2 years, patient and graft survival rates were 85.9% and 70.5% with mean serum creatinine level being 1.6 ± 0.76 mg/dl. Conclusion: we found low incidence of CMV infection as well as milder form of disease due to universal prophylaxis of valganciclovir and also due to low dosage of r-ATG (1–2 mg/kg) as induction therapy.


  Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposition in Postrenal-Transplant Recipients: Our Experience in a Tertiary Care Center Top


Megha Pai, L. Umesh, S. M. Shivaprasad, V. Leelavathi, Sreedhara, A. Kishan, V. Mahesha, V. Akila

Institute of Nephrourology, Victoria Hospital Campus, Bengaluru, Karnataka, India. E-mail: meghapai117@gmail.com

Background: Proliferative glomerulonephritis with monoclonal immunoglobulin G deposit (PGNMID), a newly described pathologic entity in native kidneys, has been recognized in kidney-transplant patients. It can present as either recurrent disease or de novo disease. Here, we present two cases of PGNMID in kidney allografts that illustrate the challenges of diagnostic approach and highlight the allograft outcome after treatment with bortezomib as a potential treatment of this condition. Aim of the Study: To study the clinicopathological profile and outcome of PGNMID in postrenal-transplant recipients. Methods: Patients with allograft biopsy showing PGNMID were included in the study. Their native kidney biopsy was reevaluated to determine the possibility of recurrence vs. de novo nature of the disease. Patients were subjected to a battery of investigations to identify the clone and were treated as per the standard protocol. Results: Patient 1: A case of Deceased donor allograft recipient whose native kidney disease was MPGN has presented with allograft dysfunction, nephrotic range proteinuria and active urinary sediment. Allograft biopsy showed PGNMID. However, the clone could not be identified on bone marrow, serum protein electrophoresis, immunofixation electrophoresis. He was treated with subcutaneous bortezomib. He is currently in complete remission. Patient 2: A case of live related ABO compatible renal allograft recipient whose native kidney disease was immune complex Glomerulonephritia and with HBsAg positive status presented with renal allograft dysfunction and active urinary sediment two months after renal transplantation. Allograft biopsy showed PGNMID. He was treated with bortezomib. However, he had an aggressive disease course and had graft loss in 2 months and is currently dialysis dependent. Conclusions: Membrano proliferative glomerulonephritis is a pattern of injury with varying causes. The most aggressive being plasma cell dyscrasias which have high chance of recurrence and early graft loss. This study shows the varying presentation and response of the same disease process in two patients. Hence, a high degree of suspicion is required during transplant workup of patients with MPGN pattern on biopsy and all possible attempts should be made to rule out plasma cell dyscrasias.


  Risk Factors for Delayed Graft Function and Outcomes of Cadaveric Renal Transplantation Top


Arjun Prakash Jagarlamudi, Rahul Devraj, S. Vidya Sagar, G. Ramchandriah, C. H. Ramreddy

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

Introduction and Objective: In India, the prevalence of end-stage renal disease is estimated to be between 151 and 232 per million population. Currently, only 7500 transplants were performed at 250 centers in India. Only 10% of these come from deceased donors. Hence there is paucity of data regarding outcomes and survival in deceased donor renal transplant in our country. Aim of our study is to analyze various donor and recipient characteristics, causes of delayed graft function, incidence of perioperative complications, graft survival, and outcomes in recipients undergoing deceased donor renal transplantation. Methods: We did a retrospective study done in our institute among patients who underwent deceased donor renal transplantation from January 2013 and July 2017. A total of 106 deceased donor transplantations were done using a standard surgical procedure. Lymphocyte cross-matching was done in all the cases. Induction therapy was given with basiliximab on postoperative day (POD) 0 and POD 4 and triple immunosuppression using prednisolone, tacrolimus, and MMF was given based on protocols. Postoperatively, renal biopsy was done in patients with delayed graft function and decreasing urine output. Patients were supported with hemodialysis/CAPD whenever necessary. Patients were closely followed up postoperatively. Results: In our study, the mean age of recipients was 39.52 + 10.35 years. Mean age of donor was 34.61 ± 12.26 years and majority of donors were males. Road traffic accident was the most common cause of brain death in donors constituting 73.58%. Most common blood group of recipient was O constituting 50.94%. Double renal artery was noted in 14.15% of cases. 77.36% of grafts were from right side. Mean cold ischemia time was 338 ± 66.27 min. Chronic glomerulonephritis was the most common native kidney disease constituting 39.62%. Delayed graft function was seen in 60.38% of patients. Four patients had wound dehiscence and seven patients developed lymphocele. Infections were the most common cause of mortality postoperatively. Mean serum creatinine at discharge was 1.8 ± 0.34 mg/dl. Donor age, recipient age, cause of brain death, history of hypertension, and diabetes had significant influence on delayed graft function. One-year patient survival was 82.72%. Death-censored graft survival at one year was 92.23%. Conclusions: Our study demonstrates good graft survival and overall survival in deceased donor transplant program in spite of prolonged cold ischemia times and multiple renal arteries. Deceased donor organ transplant has the potential to expand the donor pool and shorten the waiting list of renal transplants. Cadaver organs should be treated as nation's resource and organs wasted should be treated as lives lost.


  Nonsimultaneous Kidney Exchange Cycles without Donor Renege: A Prospective Single-Center Largest Cohort Study in 30 Donor-Recipient Pairs from Developing Country Top


V. B. Kute, H. V. Patel, P. R. Shah, H. P. Singh, D. P. Engineer, P. R. Modi, V. R. Shah, S. J. Rizvi, B. C. Pal, B. P. Butala, M. P. Modi, S. Gandhi, M. A. Rees, H. L. Trivedi

IKDRC, Ahmedabad. E-mail: drvivekkute@rediffmail.com

Recent reports suggest that the bridge donor renege is rare (1.5%) as part of nonsimultaneous kidney exchange chains. In developing countries, surgical space and resources limit the number of simultaneous kidney exchange transplant surgeries. The aim of this study was to evaluate the bridge donor renege rate during nonsimultaneous kidney exchange cycles in a prospective single center cohort study (n = 30). We describe the protocol to prepare donor-recipient pairs for nonsimultaneous surgeries designed to reduce the renege rate. We propose using standard criteria deceased donor kidneys in the event of a bridge donor renege to protect vulnerable recipients. We report 30 successful nonsimultaneous living donor kidney exchange cycles without a donor renege. We propose that nonsimultaneous kidney exchange cycles could increase living-donor kidney transplantation, especially for difficult to match sensitized pairs (13 of 30), in countries with limited transplantation resources. Our study confirms that nonsimultaneous kidney exchange cycles can be safely performed with careful patient-donor selection and nonanonymous kidney exchange.


  Pneumocystis Jiroveci in Renal Transplant: A Case Report Top


Background: Pneumocystis jirovecii pneumonia (PJP) is a potentially life-threatening infection that occurs in immunocompromised patients. A timely diagnosis of PJP is difficult and relies on imaging and detection of the organism. The aim of this study was to evaluate the risk factors for PCP in kidney transplantation recipients and study the outcomes. Material and Methods: A retrospective clinical study included all kidney transplant patients who underwent kidney transplantation at the Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan. During this period, 450 patients underwent kidney transplantation. Out of 450 patients, 10 patients had developed PJP infection after prophylaxis. Results: The median age of all recipients was 48.3 years (range, 32–60), the mean duration of prophylaxis was 6.9 months (range 3–9 months), only one patient had CMV infection, and three patients had a history of graft rejection. PJP infection occurred earlier in anti thymocyte globulin induction as compared to Simulect (IL-2R) induction and the mean duration of renal transplant slightly higher in expired patients (17.25 months) as compared to cured patients (15.5 months). Conclusion: We concluded that among renal transplant recipients, pneumocystitis pneumonia can still occur several months after transplantation, late after prophylaxis discontinuation. Graft rejection appears to be the major risk factor for PCP in these patients.


  Outcomes of Live Donor Renal Transplantation at a Tertiary Care Hospital from South India Top


Kiran K. Golimi, Rahul Devraj, S. Vidyasagar, Ramachandraiah, P. Raghuveer, G. V. Charan, C. H. Ram Reddy

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: drhpsingh.85@gmail.com

Introduction and Objectives: Renal transplantation is the treatment of choice for the patients with end-stage renal disease (ESRD). We evaluated the outcomes of live donor renal transplantation done in our institute in our institute renal transplantation started in June 1989 and around 1200 cases done till now. Methods: It is a retrospective analysis of the data from the transplant records of all the patients who underwent live donor renal transplantation between January 2013 to December 2017 at NIMS, Hyderabad. Clinical data and postoperative complications including delayed and slow graft function (DGF, SGF), medical complications, and 1-year graft and patient survival were evaluated. Observation: There were 482 patients, who underwent renal transplantation during the study period, of which 356 are live transplant cases (73. 8%). Mean age of recipient was 32.4years, predominantly males (81.5%). Mean age of the donor 44.6years, with female predominance (82.6%). In 91.3% cases, immediate graft function was present. DGF (which required dialysis) was noted in 2.9%, SGF (but no need of dialysis) was noted in 5.8%. Biopsy done in those with DGF/SGF shows acute tubular necrosis (ATN) in 69.6%, acute interstitial nephritis (AIN) in 21.3%, thrombotic microangiopathy (TMA) in 9.1% of all 33 cases. Two patients (0.05%) died within 2 weeks after surgery, one due to CVA and another due to encephalopathy. Graft nephrectomy was done in 3cases (0. 84%). Perinephric collection was noted in 3.08%, wound infection in 1.7%, and urinoma in 0.842%. There were no complications such as arterial or venous thrombosis, anastomotic leaks, and re-explorations. 96.1% cases survived up to1 year. 14 cases (3.93%) died within 1 year most due to infection. In patients who survived, graft survival rate was 99.2%. Conclusion: Live renal transplantation is a viable option for patients with ESRD. Surgical complications are minimal in our group of patients. One-year graft survival was good among them and the most common cause of mortality was infections.


  Induction (+/-) in Deceased Donor Renal Transplants and Outcome Top


T. Aswini Dutt, P. S. Vali, Kiranmai Ismal, Manisha Sahay

Department of Nephrology, Osmania Hospital, Hyderabad, Telangana, India. E-mail: aswinidutt10@gmail. com

Introduction: Kidney transplantation is considered the treatment modality of choice for majority of patients with ESRD. In India, there are a large number of ESRD patients waiting for renal transplant. The two sources of kidneys for transplantation are deceased and live donor. Rejections are an important cause of poor graft outcomes. Acute rejection episodes are considered as a risk factor in the development of chronic rejection. Induction therapy is recommended for deceased donor transplants; however, the cost of induction therapy is high. Aims and Objectives: To study and compare complications and outcome of deceased donor renal transplantation in patients with and without induction therapy. Materials and Methods: Our study is a prospective observational study of 58 deceased donor transplants performed at tertiary care government hospital between December 2015 and December 2017, to determine the factors that affect the graft and patient outcomes. The primary endpoint of the study is defined by the occurrence of acute graft rejection confirmed histologically during 12 months following transplant. Secondary parameters were episodes of infectious complications and 12-month graft function and patient survival. Group 1 (29) received no induction. Group 2 (29) received Induction therapy with basiliximab. Inclusion Criteria: All patients underwent cadaveric renal transplantation were included. Exclusion Criteria: (1) ABO incompatibility; (2) patients who are not willing to give informed consent; (3) living-related renal transplantation. The sample size was calculated to detect the difference between two groups, induction versus no induction at 5% significance level. The proportion of patients experiencing biopsy-proven acute rejection, infectious complication, graft function, and patient survival were analyzed using ANOVA test. Results are reported as mean ± standard deviation. P < 0.05 was used for statistical significance. Results: Majority of the group 1 patients were in 21–30 years (41.3%), 86% were males, and 14% were females. NKD-CGN (17.24%), CIN – 82.76%. Dialysis vintage in group 1 was 33.72 months. Cold ischemic time (mean) in group 1 was 6.5 h. CMV (D+/R+) – 34.5%, CMV (D-/R+) – 34.5%, CMV (D+/R−) – 17.2%, CMV (D−/R−) – 13.8%. Infections – bacterial (24.1%), fungal (13.8%), viral (10.3%), DGF – 27.5%, acute rejection – 17.2%, CNI toxicity (6.9%), chronic rejection (3.4%), CAN – (10.3%). Creatinine at 1 year was 1.32±, graft survival at 1 year was 75.9%, and patient survival at 1 year was 79.3%. Majority of the group 2 patients are in 31–40 years (34.5%), gender – 79.3% were males and 20.6% were females. NKD–CGN (44.8%), CIN – 55.2%. Dialysis vintage mean in group 2 was 27.4 months. All patients received induction with two doses of basiliximab. Cold ischemic time mean in group 2 was 8.3 h. CMV (D+/R+) – 37.9%, CMV (D−/R+) – 27.6%, CMV (D+/R−) – 13.8%, CMV(D−/R−) – 20.7%. Infections – bacterial (13.8%), fungal (13.8%), viral (13.7%). DGF – 31%, acute rejection – 6.9%, CNI toxicity – 3.44%, CAN – 3.44%. Creatinine at 1 year was 1.24± mg/dl, graft survival at 1 year was 79.3%, and patient survival at 1 year was 79.3%. Conclusion: Acute rejection and chronic allograft nephropathy was more common in group 1 than group 2; however, the graft and patient survival at 1 year was not significantly different among the two groups. Limitations: Only 1-year follow-up study, which may require further follow-up to assess graft and patient survival among the patients with and without induction.


  Deceased Donors and Their Kidney Donor Profile Index Score: Single-Center Study Top


Arun Kumar Ponna, Manisha Sahay, Kiranmai, P. S. Vali

Osmania Medical College, Hyderabad, Telangana, India. E-mail: arunponna@gmail.com

Aim: Declining use of expanded criteria donors (ECDs) despite improvement in survival and quality of life is a concern. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. A donor KDPI >85% (DK85) is thought to be equivalent to an ECD kidney. Methods: We analyzed data from over 36 deceased donor kidney or combined kidney and pancreas transplants between 2013 and 2018. Ten parameters (age, race, history of hypertension, diabetes, HCV infection, cause of brain death, any signs of cardiac death, height, weight, and creatinine) were taken into consideration and KDPI scores were calculated. Results: 36 cases of cadaver kidney donation were noted. 30 (83%) were males and 6 (17%) were females. The mean age at donation was 36.26 ± 2.12 years. Hypertension was noted in one donor and no diabetic donors. The cause of brain death was head trauma in 31 patients and cerebrovascular accident in five donors. The mean serum creatinine was 1.22 ± 0.32 mg/dl. Five donors had KDPI score >80%, four donors had KDPI score in between 60% and 80%. 27 donors had KDPI <60%. Delayed graft function was seen in 40% and 50% recipients who received kidney from donors with KDPI >80% and KDPI 60%–80%, respectively. Recipients experience an increase in the rate of DGF as their KDPI increases. Recipients have good graft function at 1-year posttransplant, whose donors have KDPI score of <60%. Conclusion: The KDPI score is an accurate predictor of donor contributions to transplant outcomes and should be performed routinely.


  Women Donate, Men Receive: The Lopsided Truth about Organ Donations Top


G. S. Karthik, P. S. Vali, Kiranmai, Manisha Sahay

Department of Nephrology Osmania General Hospital, Hyderabad, Telangana, India. E-mail: drkarthik05@gmail.com

Aim: The aim of present study is to analyze the gender differences and impact of gender in renal transplant and their outcomes. Materials and Methods: Medical records of all patients who underwent renal transplant either living-related or deceased donor in Osmania General Hospital between 2008 and 2018 were included in this study. Patients not on follow-up or those with multiple transplants were excluded from study. Impact of gender on outcomes was studied. Results: This study includes total kidney recipient of 295 patients, with median age of 34 years, out of which 259(87%) were living-related renal allograft recipient and 36(12%) were deceased donor renal-allograft recipients. Among living donor recipients, 29 (11%) were females, 230 (88%) were males, while among deceased donor renal-allograft recipients, 6 (16%) were female, and 30 (83%) were males. Among donors for live transplant among which 182(70%) were females, males were 77(29%). Among female donors, 146 (80%) were mothers, 32 (17%) were sisters, 1 (0.05%) were daughter, and 2 (0.1%) were wives. Among male donors, 53(68%) were fathers and 24 (31%) were brothers. Sons did not donate in our series. In deceased donors, among 36 donors, 8 (22%) were females while 28 (77%) were males. On comparison of outcomes, male recipients from female donors were found to have chronic allograft nephropathy in 76 (33%), 43 (18%) had delayed graft function, 23(10%) had vascular anastomotic leak, 30(13%) has serious fungal infections. Among female recipients from female donors, 5(17%) had chronic allograft nephropathy, 6 (20%) had delayed graft function, 4 (13%) had serious fungal infections, and 2(6%) had vascular anastomotic leaks. Conclusion: There is a significant gender disparity in donors for kidney transplants with more females donating their kidneys and more males receiving the kidneys. Male gender as a recipient from female donor appears to be as a risk factor for graft survival. This gender disparity in living transplant reflects the social fabric in India and needs to change. Women, nurturers, sustainers, givers of life – it almost seems natural that in times of need, a woman will step up to donate a kidney to save a loved one. However, in deceased donor transplants, male donors outnumber females. This is because most deceased donors are victims of road traffic accidents and predominantly males. Poor outcomes in female to male recipients may reflect lower nephron number in females and or greater expression of more HLA antigen. Existing practices in the organ transplantation process should be reviewed to eliminate the donor gender disparity in India.


  Outcomes and Follow-Up of Living Kidney Donors Top


R. Sujith Reddy, Manisha Sahay, Kiranmai, P. S. Vali

Osmania Medical College, Hyderabad, Telangana, India. E-mail: jeet.0311@gmail.com

Aim: The increase of live kidney donation (LKD) demands that we scrutinize its long-term consequences. Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation. We have retrospectively analyzed the general health status and renal consequences of living-related kidney donation. Methods: Living-related kidney donors were called for follow up, who had donated their kidneys from 1990 to 2018. Data on age, sex, relation to recipient, weight, blood pressure, serum creatinine and creatinine estimation, level of proteinuria, uric acid levels, renal length by ultrasonography, and new-onset diabetes mellitus were analyzed. Donors with comorbidities not related to nephrectomy were excluded from the analysis. Results: 210 cases of living kidney donation were noted. 80 cases attended the follow-up center. Since kidney donation, a mean time interval of 64 months (3–332 months) had elapsed. 34 (44%) were males and 46 (56%) were females. Parents constituted the majority 64 (78%), 15 were siblings (20%), and 1 was a spousal donor. The mean age at donation was 41.26 ± 8.12 years. There was a mean rise of 9.96 mmHg in systolic blood pressure and 7.18 mmHg in diastolic blood pressure. Hypertension was noted in 13 (16%). 20 donors (25%) developed microalbuminuria postnephrectomy and 10 (12%) developed overt proteinuria (>300 mg/day). Incidence of proteinuria was seen mostly in age group 40–49 years. New-onset diabetes was seen in five (6%) patients, mostly in age group of 50–59 years. Hyperurecimia was observed in three (4%) donors. Mean GFR pre- and post-nephrectomy was 96.4 ± 6.91 and 73.54 ± 14.64 ml/min, with a mean reduction of 24.2 ± 13.57 ml/min. There was no significant change in serum creatinine after donation (0.97 ± 0.09 mg/dl vs. 1.22 ± 0.82 mg/dl) (P > 0.01). There was an increase in renal length of 1.14 ± 0.73 cm. Conclusion: A significant number of donors demonstrated proteinuria and elevated blood pressure levels and inadequate antihypertensive treatment due to poor follow-up. No case of end-stage renal disease was identified. A relatively large number of donors did not receive regular check-ups and preventive measures. Both of these issues demonstrate the need for a better-structured lifelong follow-up.





 
 
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